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PM& R Lecture Series. Therapeutic Physical Agents. Physical Medicine. the application of physical agents such as: heat cold sound water electricity and other mechanical agents in the treatment of disease. Therapeutic Heat . Physiologic Effects:

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Pm r lecture series

PM& R Lecture Series

Therapeutic Physical Agents

Physical medicine
Physical Medicine

  • the application of physical agents such as:

    • heat

    • cold

    • sound

    • water

    • electricity and other mechanical agents

      in the treatment of disease.

Therapeutic heat
Therapeutic Heat

  • Physiologic Effects:

    • Increase of 3oC increases collagenase activity

      • Heating hands to 450C reduces MCPJ stiffness by 20%

    • Changes of 5-7oC alter blood flow and collagen extensibility

    • Hot paraffin increases local skin temp by 7.5oC and intraarticular temp by 1.7oC

Therapeutic heat2
Therapeutic Heat


  • relief of pain

  • relief of spasm

  • increased exetensibility of collagen tissue (e.g. fractures/contractures)

  • decreased joint stiffness (OA, RA)

  • increased blood flow

    * remember, the physiologic effects of heat manifest themselves only if the heat is applied for at least twenty minutes at a temperature of 40-45o C.

General indications


Muscle spasm


Tension myalgia

Production of hyperemia

Acceleration of metabolic process

Hematoma resolution





Superficial thrombophlebitis

Induction of reflex vasodilatation

Collagen vascular disease

General Indications

General contraindications

Acute inflammation, trauma or hemorrhage

Bleeding disorders

Cutaneous insensitivity

Inability to communicate or respond to pain

Poor thermal regulation




Atrophic skin

Scar tissue

Unstable angina or blood pressure

Decompensated heart failure within 6 to 8 weeks of an MI

General Contraindications

Hot moist packs
Hot Moist Packs

  • applied at a temperature of 46oC

  • stays warm for twenty minutes or more

  • inc blood flow by as much as 68%

  • sacks filled with silica gel (expensive)

  • blood flow doesn’t return to resting level until 40 mins. after cessation

  • for analgesia and muscle relaxation

Paraffin wax bath
Paraffin Wax Bath

  • applied at a temperature of 45-54oC

  • solution contains 1 part mineral oil (useful for those whose skin had undergone trophic changes) to 7 parts paraffin (can be tolerated by px with sensory deficits)

  • higher temperature is tolerable without the risk of burns (due to high specific heat of paraffin)

  • commonly used on the hand and wrist and other uneven surfaces

Paraffin wax bath1
Paraffin Wax Bath

  • Dipping technique

    • Immerse part 6-10 times to build up layers of paraffin

    • Followed by wrapping extremity with an insulating cover

    • Skin temp achieved: 47oC

    • Subcutaneous temp change of 3oC

    • Intraarticular temp change of around 1oC

  • Continuous immersion

    • Dipped 6-10 times, then kept immersed for 20-30 mins

    • Subcutaneous temp change of 50C

    • Intraarticular temp change of 3oC

Infrared radiation
Infrared Radiation

  • Uses that portion of the EMS from 7700-150000 A

  • Maximum penetration of 3mm (superficial)

  • Dry heat (less comfortable)

  • Commonly used to decrease skin resistance by inc. blood flow (e.g. in Bell’s palsy)

  • Wound healing and other dermatological conditions (dries up wound but has no other effects unlike UV light)

  • Heat inversely proportional to distance and angle of delivery

  • Usual distance about 40-50 cm and perpendicular to surface treated


  • applied at a temperature of 33-43oC

  • full body immersion can increase core temp by 0.3oC

  • heat and exercise can be done at the same time

  • bouyancy effect permits easier movement of weak or painful extremities

  • agitation of medium permits gentle debridement (e.g. for burns)


  • Convection heating modality

  • Uses cellulose particles suspended in jets of warm air

Contrast bath
Contrast Bath

  • One bath at 38 to 40oC

  • The other bath at 13 to 16oC

  • Produces reflex hyperemia and neurologic desentisization

  • Initial soaking in warm bath for 10 mins

  • Followed by 4 cycles of alternate 1 to 4 minute cold soaks and 4-6 minute warm soak

  • Ends with cold soak to minimize edema

  • Used in treatment of CRPS type I (RSD)

Ultrasound diathermy
Ultrasound Diathermy

  • involves conversion of sound waves at a frequency faster than 17000-20000 cycles/sec

  • applied to tissues causing mechanical vibration which dissipates heat

  • deepest penetrating agent; only agent that can significantly heat the hip jt. (by 8-10oC)

  • both thermal and nonthermal effects

Ultrasound diathermy1
Ultrasound Diathermy

  • Nonthermal effects

    • Cavitation

      • US travelling through liquid produces bubbles which oscillate in size

    • Streaming

      • Produces shear forces in tissue that may accelerate metabolic processes

    • Standing waves

      • Produces areas of alternating high and low pressure

Ultrasound diathermy2
Ultrasound Diathermy

  • Penetration dependent upon:

    • Type of tissue

    • Frequency (usually 1 or 3 MHz)

    • Angle of orientation

Ultrasound half value depth in millimeters
Ultrasound Half Value Depth in Millimeters

Kitchen and Bazin(1996) Clayton’s Electrotherapy 10th ed.

Ultrasound diathermy3
Ultrasound Diathermy

  • Indications

    • Musculoskeletal conditions (tendinitis, arthritis, patellofemoral pain)

    • Contractures

    • Wounds and inflammation

    • Trauma (subacute phase)

    • Fractures

Ultrasound diathermy4
Ultrasound Diathermy

  • Contraindications

    • Fluid filled cavities (eyes, gravid uterus)

    • Spinal cord, esp laminectomy sites

    • Immature bone (e.g. children)

    • Heart, brain, cervical ganglia

    • Metal implants

    • Methylmethacrylate implants (plastics, bone cement)

    • Acute inflammation


General Musculoskeletal


Muscle spasm

Joint stiffness


Tissue Repair:

Soft tissue repair

Stimulation of blood flow

Bone fracture repair

Tendon repair






Shortwave diathermy
Shortwave diathermy

  • involves conversion of radiofrequency EM current into heat energy

  • commonly uses 27.12 Mhz

  • uses condenser pads, plates and internal metal electrodes for heat transfer (not very convenient)

  • penetration between skin and subcutaneous tissue

  • Can heat larger areas than ultrasound

Shortwave diathermy1
Shortwave diathermy

  • Inductive applicators

    • Generate magnetic eddy currents in tissue

    • Highest temperature in water rich, highly conductive tissue (e.g. muscle)

  • Capacitively coupled applicators

    • Generate electrical fields

    • Highest temperature in water poor tissue like fat, ligament, tendon or joint capsules

  • May be pulsed or continuous

Microwave diathermy
Microwave diathermy

  • Uses 915 and 2456 MHz

  • Does not penetrate as deeply as SWD or US

  • Highest temperatures are achieved at the fat-muscle interface

Therapeutic cold
Therapeutic Cold

  • Decreases collagenase activity

    • Cooling hands to 180C increases MCPJ stiffness by 20%

  • Icing an acutely inflamed knee

    • Decreases skin temp by 160 C

    • Decreases intraarticular temp by 5-60 C

Therapeutic cold1
Therapeutic Cold

* cold can also stimulate a-motor neurons and cause muscles to contract rather than relax

General indications1

Acute musculoskeletal trauma






Adjunct in muscle reeducation

Reduction of local and systemic metabolic activity

General Indications

General contraindications1


Cold intolerance

Raynaud’s phenomenon or disease

Severe cold pressor responses

Cold allergy

Inability to communicate or respond to pain

Poor thermal regulation

Cutaneous insensitivity

General Contraindications

Therapeutic cold2
Therapeutic Cold

  • Modalities

    • ice packs

    • cryogel packs

    • ice immersion

    • ice cube

    • ethyl chloride spray


Transcutaneous Electrical Nerve Stimulation (TENS)

  • two theories:

    • gate control theory:

      • electrical stimulus carried through large a-fibers which arrive at the substantiagelatinosa before the pain impulses traveling through the c-fibers.

      • treatment is effective only during application.

    • endorphin stimulation:

      • TENS stimulates production of natural analgesics.

      • Treatment is effective even after cessation.


  • high frequency, low intensity

    • stimulates large diameter afferent fibers

  • Low frequency, high intensity

    • endorphin stimulation

Other modalities
Other Modalities

  • Low power laser

    • Not a heating modality

    • Stimulates collagen production, alters DNA synthesis, improves function of damaged nerves

    • FDA approved for CTS, neck, and shoulder pain

Other modalities1
Other Modalities

  • UV light

    • no heating function

    • uses part of EMS between 1800-2900 angstroms

    • dose is determined by testing called Minimum Erythemal Dose (MED); erythema should appear w/in 30 mins- 1 hr and disappear after 24 hrs.

    • penetration does not exceed 0.1 mm

    • bactericidal (helps wound healing)

    • anti-rachitic (vit. D formation

    • Anti-psoriatic