Download MBBS Physical Medicine and Rehabilitation Presentations 14 Physical Agent Modalities 1 Lecture Notes

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n Modalities are physical agents that are used to produce

therapeutic responses in tissue.

- Cold

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- Heat

- Sound

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- Electromagnetic waves

- Electric currents

- Water

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n Adjunctive treatments rather than primary cure.
Cold ( Cryotherapy )

Physiological Effects

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n Hemodynamic

? Immediate cutaneous vasoconstriction

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? Delayed reactive vasodilatation

? Decreased acute inflammation

n Neuromuscular

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? Slowing of conduction velocity

? Increased maximal isometric strength

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? Decreased muscle fatigue

? Temporarily reduced spasticity
Physiological Effects

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n Joint and connective tissue

? Increased joint stiffness
? Decreased tendon extendibility
? Decreased col agenase activity

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n Miscellaneous (acute conditions)

? Decreased pain
? General relaxation

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General uses of cryotherapy

n Acute musculoskeletal conditions (sprains, strains, tendinitis,

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tenosynovitis, bursitis, capsulitis, etc)

n Myofascial pain
n Fol owing certain orthopedic surgeries
n Component of spasticity management

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n Emergency treatment of minor burns


General precautions for use of cold

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n Cold intolerance
n Cryotherapy induced neurapraxia/ axonotmesis
n Arterial insufficiency
n Impaired sensation
n Cognitive or communication deficits that preclude

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reporting of pain.

n Cryopathies
n Cryoglobulinemia

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n Paroxysmal cold hemoglobinuria
n Cold hypersensitivity
n Raynaud's disease/ phenmenon

Cryotherapy agents

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1. Cold packs

- Hydrocol ator packs: Cooled in freezer to -12? C

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and applied over a moist towel.

- Ice packs: Easily used at home and best applied

with elastic bandage or tape.

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n

Duration 20 to 30 min.

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n

skin is cooled immediately,

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sc tissue within mins &

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muscle at depth of 2 cm cooled by 5? C after 20 min.


Cryotherapy agents

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2. Ice massage

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The direct application of ice to skin using gentle

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stroking motions

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Combines therapeutic effects of cooling with

mechanical effects of massage

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Water is frozen in a paper cup, with ice being exposed

by tearing the top rim of paper off as the ice melts.

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n

Used for localized symptoms and applied for 5 to 10

min per site.

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Cryotherapy agents

3. Cryotherapy compression units
n Cuff or boot through which cold water is circulated

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and can be pneumatically compressed statically or

serially

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n distal to proximal pumping action.
n Combine beneficial effects of cryotherapy with

advantages of pneumatic compression.

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n Used primarily after acute musculoskeletal injury with

soft tissue swelling, and after some surgical

procedures.

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n Typical temperatures of 7.2? C and pressures up to

60 mm Hg are used.
Cryotherapy agents

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4. Cold water immersion

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Best suited for circumferential cooling of the limbs,

localised burns

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5 - 13? C.

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Often uncomfortable and poorly tolerated

HEAT
Physiological effects

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Hemodynamic
- Increased blood flow

- Increased edema

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- Increased bleeding

- Increased acute inflammation

- Decreased chronic inflammation

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Neuromuscular

- Increased nerve conduction velocity

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Physiological effects

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Joint &connective tissue
- Increased tendon extensibility
- Increased col agenase activity
- Decreased joint stiffness

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Miscel aneous (chronic conditions)
- Decreased pain
- General relaxation

General uses of heat

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1. Musculoskeletal conditions (tendinitis, tenosynovitis,

bursitis, capsulitis, etc)

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2. Pain (neck, low back, myofascial, neuromas,

postherpetic neuralgia, etc)

3. Arthritis

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4. Contracture

5. Muscle relaxation

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6. Chronic inflammation

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General precautions for use of heat

n Acute trauma, inflammation
n Impaired circulation

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n Bleeding diatheses
n Edema
n Large scars
n Impaired sensation
n Malignancy

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n Cognitive or communication deficit that preclude reporting of

pain.

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Classification of various types of

heating
SUPERFICIAL HEAT
1. Hot packs and heating pads (conduction)

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2. Paraffin wax baths (conduction)
3. Fluidotherapy (convection)
4. Whirlpool bath (convection)
5. Radiant heat (radiation)

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DEEP HEAT
6. Ultrasound (conversion)
7. Shortwave diathermy (conversion)
8. Microwave diathermy (conversion)

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Superficial heat

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Superficial heating agents achieve their maximum tissue

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temperature in skin and subcutaneous fat.

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Deeper tissue heating is limited by vasodilatation and insulating

fat.

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Used in OA, RA, neck pain, LBP, muscle pain syndromes, and

variety of musculoskeletal conditions.

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Superficial heat

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1. Hot packs
n Commercial y available hot packs (Hydrocol ator packs) contain

silicon dioxide encased in canvas pack.

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n They are immersed in tanks at 74.5 C and applied over several

layers of insulating towels.

n Total treatment time is usual y 30 min.

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n In addition to general heat precautions, patient should not lie on

the packs.

n They are among the more common causes of burn in physical

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modalities

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Superficial heat

2. Heating pads

n Two types :

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1) electric heating pads (control heat output by regulating current

flow)

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2) circulating fluid pads (control heat output thermostatical y)

n Peak temperature of nearly 52? C achieved with electric heating pad

set on lowest setting.

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n In case of electric heating pads, potential of electric shock with moist

toweling.

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n Patient should not lie on heating pad, as it can lead to burns (Of

particular concern in slender or cachectic patients)

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Superficial heat

3. Paraffin wax bath

n

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Paraffin wax: Mineral - 6:1 or 7:1.

n

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52.2? C to 54.4? C

n

Methods of application are:

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1) Dipping: 7 to 12 dips fol owed by wrapping in plastic and

towels or insulated mitts,

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2) Immersion: Several dips to form a thin glove of paraffin

fol owed by immersion for 30 min. Produces greatest quantity and

duration of temperature increase.

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3) Brushing: brushing on several coats of paraffin, fol owed by

covering with towels.

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- More cumbersome.

- Improves treatment compliance in children.

- Useful for areas difficult to immerse.

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n

Open wounds and infected areas should be avoided.

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Superficial heat

4. Radiant heat
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Luminous infrared heat lamps emit radiation in the near ?infrared

spectrum (wavelength 770 to 1500 nm) and non-luminous infrared

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lamps emit radiation in the far infrared spectrum (wavelength 1500 to

12500 nm)

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Infrared radiation produces heating by inducing molecular vibration.

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Preferable in patients who cannot tolerate the weight of hot packs.

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Caveats for radiant heat use: General heat precautions, light sensitivity,

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skin drying and dermal photoaging.


Deep Heat (Diathermy)

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n Deep heat or diathermy, unlike superficial heat, affects the target

tissues like muscle, tendon, ligament, bone without significant

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heating of skin and subcutaneous tissue.

n Therapeutic target temperature ranges from 40? C to 45? C.

Deep Heat

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1. Ultraound

n >20,000 Hz.
n Reverse piezoelectric effect.

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n Most commonly clinically used frequencies are in

the range of 0.8 to 1.1 MHz, although up to 3.0 MHz

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are used.

n Ultrasonic energy is absorbed by the tissues ( esp. at

interface) and is ultimately converted into heat via

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molecular vibrations, a phenomenon of conversion.
Deep Heat

n A coupling agent is used to prevent reflection of

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greater fraction of acoustic

n Commonly used are: Degassed water, mineral oils,

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encased silicon gel commercially available coupling

gels .

n Temperatures of upto 46 C are achieved in deep

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tissues.

n Duration is generally 5 to 10 min per site
n Ideal for very deep heating e.g hip joint, in such cases

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superior to shortwave and microwave diathermy.

Deep Heat

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Precautions for Ultrasound
1. General heat precautions
2. Near brain, eye, reproductive organs
3. Gravid or menstruating uterus
4. Near pacemaker near spine, laminectomy sites

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5. Malignancy
6. Skeletal immaturity
7. Arthroplasties
8. Methyle methacrylate or high density polyethylene

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Other Modalities

2. Phonophoresis

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n

Standard ultrasonic coupling gel is mixed with various

chemical substances to produce phonophoresis

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coupling agent.

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Local analgesic gels, corticosteroids

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Anti-inflammatory effects of ultrasonic and

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corticosteroids act synergistically.

Deep Heat

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3. Shortwave diathermy

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Oscillation of high frequency electrical and magnetic

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fields produces movement of ions, rotation of polar

molecules and distortion of non-polar molecules,

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resulting in heat generation.

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Most commonly used frequency is 27.12 MHz &

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treatment time is 20-30 min

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Heating produced depends on type of shortwave unit,

and on the water content and electrical properties of

tissues.

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Deep Heat

n Precautions:

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- General heat precautions

- Metal (jewelry, IUD's, surgical implants, deep brain stimulator

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and pacemaker which is absolute contraindication).

- Contact lenses (Potential for focal heating).

- Gravid or menstruating uterus

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- Skeletal immaturity

Hydrotherapy

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n

External application of hot or cold water, in any form, for treatment

of disease.

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n

Arthritis and variety of musculoskeletal conditions, and in

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cleansing and debridement of burns and other dermal injuries.

Whirlpool baths and Hubbard tanks
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Typical y used for treatment of a limb or localized lesion.


Hydrotherapy

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3. Contrast baths

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Consists of alternating immersion of the distal limbs

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in hot (42 - 45 C) ,then cold (8.5 ? 12.5 C) water.

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30 min treatment session are typical, beginning with

10 min immersion in hot, followed by alternating

immersions of 1 min cold and 4 min hot, ending

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with cold immersion.

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Especially suited for rheumatological disease,

neuropathic pain, other chronic pain syndromes like

complex regional pain syndrome.

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Other Modalities

Interferential current therapy (IFT)

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n

Periodic interference of two AC signals of slightly

different frequency, results in a new wave with cyclic

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modulation of amplitude, due to cyclic constructive and

destructive interferencere.

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n

IFT machines typically uses medium frequency

currents of 4000 ? 5000 Hz.

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n

Most machines use 2,4 or 6 applicators, which can be

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arranged in same plane (planar) as in lumbar area or in

different planes (coplanar) as in the shoulder.

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Useful in variety of musculoskeletal conditions,

neurological conditions and management of urinary

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incontinence.
Other Modalities

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Precautions :

- near implanted stimulators (pacemakers,

intrathecal pumps, spinal cord stimulators)

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- near sympathetic ganglia or carotid sinus
- near open incision or abrasions
- near gravid uterus
- in the presence of venous thrombosis

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- near SWD.

Factors to consider in

Modality Selection

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1.

Target tissue

2.

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Depth of heating/cooling/therapeutic response desired

3.

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Intensity of heating or cooling desired

4.

Body habitus ( i.e amount of subcutaneous adipose)

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5.

Co-morbid conditions ( e.g. malignancy, vascular disease,

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neuropathy ,etc)

6.

Associated pt. specific features ( e.g. metal implants,

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pacemaker, cold al ergy etc)

7.

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Age (e.g. Open epiphysis)

8.

Sex (e.g. pregnant female)

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