A gentle sustained pressure which can be applied to any portion of the body i.e., trunk, neck, skull, extremities to release restrictions (barriers) within the deeper layers of fascia. This is accomplished by a stretching of the cross links and changing the viscosity of the ground substance of the fascia. Deep releases are performed all over the body in all directions depending on where the fascial restriction is located.
- Physical Trauma
- Inflammatory / Infectious process
- Osseous restrictions
- Structural Imbalance from Dental Malocclusion
- Leg Length discrepancy
- Postural Imbalance
- Acute Rheumatoid Arthritis
- Open Wounds with caution
- Hematoma with caution
- Healing fracture with caution
People throughout the ages have treated physical complaints and sought relief from discomfort by applying heat or cold to their bodies in some way. At present, both heat and cold are widely used physical therapy modalities. Initially a thermal modality can be the primary part of a treatment program. Such a program is acceptable when it is likely that the physiological or psychological changes produced of themselves, can alleviate the patient’s problem (eg, when one applies ice immediately after an injury to stop bleeding or soaks in a hot bath to sooth mental anxiety and tension). More often, however, thermal modalities are used as an adjunct to other physical therapy treatments. For example, before therapeutic exercise -passive range of motion or mobilization procedures- heat or cold can be applied to prepare body tissues or reduce pain. Thus, patients may benefit more from treatment procedures that are to follow.
Conclusive evidence, however, is lacking regarding some physiological responses to changes in tissue temperature and, in some instances, controversy exists concerning the therapeutic benefits. Although studies can be cited to reinforce opposing viewpoints, more studies need to be done to determine whether and when one thermal agent is significantly better clinically than the other.
Heat modalities can be categorized as either superficial or deep. A superficial heat modality refers to heat that, when applied at a maximally safe clinical dosage, is only capable of raising the temperature of superficial tissues to a therapeutically significant level. Although these modalities may increase the skin temperature by 18° F (10° C), the increase in temperature of tissues 1 cm deep will be less than 6° F (3° C) and that of tissues 2 cm deep about 2° F (1.3° C).
Superficial heat can be either moist or dry, depending on the source of the heat. If the source is with little moisture (eg, a heating pad or warm dry air), it is called a dry heat modality. If the heat source is water, another fluid, moist air, or a modality containing moisture (eg, a hot pack), it is called moist heat.
The term deep heat modality implies that a form of energy other than heat is transmitted through the skin and is absorbed in deeper tissues, where it increases the kinetic action of molecules. Thus, forms of energy such as electromagnetic energy (diathermy) and acoustic energy (ultrasound), which can be transmitted to deeper tissues, increase the temperature of those tissues. These modalities produce heat as a result of energy conversion.
Physiologic Effects of Heating
Any addition of heat to the body may trigger certain physiologic responses. For example, local application of superficial heat in the form of hot packs, paraffin, and Fluidotherapy, can lead to many beneficial local physical changes and may or may not affect systemic factors such as the core (internal) temperature.
Some physiologic responses to heat are increases in tissue temperature, local metabolism, and blood flow. In addition, heat causes both analgesia and sedation (relaxation), which are helpful in chronic conditions. Local heating also leads to increased nerve conduction velocity.
Superficial heat will heat the surface of the body or the underlying tissue to a depth of a few millimeters. Any transfer of heat that takes place is a result of radiation, conduction, or convection.
The decrease in muscle spasm and the decrease in pain resulting from local heating are closely interrelated. Sometimes a patient “guards” a painful affected part and increases muscle tension in that area. If this cycle can be broken by local heating, the the part can be treated easily with massage, exercise, or other modalities. Local heating also may help reduce skin resistance, thus making this modality desirable to use before other modalities such as electrical stimulation are applied.
Heat is not recommended during the first 24 to 36 hours after an injury if a hemorrhage is present, but it can be used subsequently to hasten healing, alleviate local edema, and aid in resorption of a hematoma. Vigorous heating should not be used if a patient has severe edema caused by renal or cardiac failure or has severely impaired circulation and therefore an impaired thermoregulatory system.
Superficial heating modalities are useful in the following situations; remember, however, that superficial heating will only affect superficial tissue-that the effects on deeper tissues such as muscle are minimal or nonexistent. However, vigorous or prolonged superficial heating can cause systemic changes.
- Before active exercise because of their analgesic and sedative effects.
- Before passive range of motion (stretching) exercises because they promote relaxation and provide grater extensibility of soft tissue.
- Before/during electrical stimulation because they reduce skin impedance.
- Before/during traction because they promote general relaxation and decreased tension in muscles in area receiving traction.
- Before massage because thy increase local blood flow and relax the tissue.
- In the presence of muscle spasm because thy help relax the patient.
- Before ultrasound because they relax the patient and warm the local superficial tissue.
- Before joint mobilization procedures because they relax the patient and improve the extensibility or superficial soft tissue.
The contraindications listed below are relative to the intensity of the heat : vigorous heat will cause greater reactions than mild heat.
- If an injury is at a stage where bleeding or edema may still be present, the heat could exacerbate both problems.
- In the presence of deep vein thrombophlebitis, increased heating and blood flow could dislodge a clot and cause more serious problems such as a stroke or blockage of a coronary artery.
- In areas with poor circulation, eg, in peripheral vascular disease, the body cannot dissipate heat.
- If a patient has dysesthesia and therefore cannot discern excessive heat, he or she may sustain a burn.
- In areas where sensation is reduced, eg, in scarred areas, a burn may occur.
- If a patient is very old or very young, he or she may not tolerate heat modalities because of an inability to control body temperature easily.
- If a patient cannot report heat sensations accurately, eg, because of senile dementia, a burn may occur.
- In the presence of skin or lymphatic cancer, superficial heat may be contraindicated because the safety of its use in the presence of cancer has not been determined.
Uvalde Memorial Hospital Physical Therapy clinic has the following superficial heat modalities available: hot packs (chemical-silica gel), paraffin, Fluidotherapy, and hydrotherapy.
Chemical hot packs, a frequently used superficial heat modality, transmit moist heat to body tissues by conduction. The patient should experience a sensation of pleasant warmth. The usual duration of treatment is 20-30 minutes. Hot packs should be avoided when a patient has a local infection or some other dermatologic irritation that could be adversely affected by moist heat. To avoid the risk of a burn, the patient should be aware of the true heat of the pack and should speak up if more toweling is required..
Paraffin or “Hot Wax Treatment” is another superficial heating method used to treat chronic joint disorders. This modality also transfers heat by conduction. Initially, the patient will experience a hot, but not painful sensation of heat, but the sensation will be one of pleasant warmth after about 3 to 5 minutes.
A part with open wounds should never be treated in the paraffin tank because the wound and the tank can become contaminated. Some joints of the body are not accessible for immersion techniques. Although the brush method can be used, other heating methods may be more advantageous and easier to apply. Paraffin can be a messy procedure if the wax is not removed directly over the tank or protective covering.
Studies on the value of paraffin treatments are few. Studies on the temperature of skin and underlying tissues after a 20-minute treatment would help substantiate the value of this method of treatment. After 1-2 treatments in the clinic, usually the patient will be taught how to do this heat treatment at home.
Another form of superficial heating available is fluidotherapy, which can be used as an alternative to paraffin or hydrotherapy in some instances or when dry heat is desirable. This modality transfers heat by convection.
Fluidotherapy has been in existence since the 1970’s, but the construction of the unit has changed slightly over the years. Extremely small solid particles are heated and suspended by circulating air, thus producing an effect similar to circulating warm liquid. The thermal conductivity and specific heat of the particles and air allow the temperature of the unit to be higher than that of water used therapeutically. That is, the patient can safely tolerate a higher temperature. The feeling produced by the unit resembles that produced by placing a hand in a small enclosed sandbox with heated, air-blown sand.
The duration of treatment is usually 20 minutes. The machine stands 3 feet high and contains a heating element, and air compressor, tiny silicon or corn-cob particles in an enclosed see-through container into which the limb is inserted, a timer , a temperature gauge, and a mesh sleeve. The sleeve can be closed snugly around the proximal portion or the arm or leg, thus preventing the circulating particles from blowing into the room. There are usually four openings for the insertion of a limb: two on the top of the unit, which are best for a hand, and two on the side for hand or foot.
Hydro therapy or whirlpool therapy with its unique physical properties including buoyancy, hydrostatic pressure, surface tension, cohesion, adhesive and fluidity as well as its thermal properties is beneficial to treat soft tissue injuries, contusions, inflammatory conditions, stiff joints, circulatory impairments and open wounds. Precaution is taken with patients who exhibit severe circulatory or sensory impairments and with severe non-inflammatory edemas.
Deep Heat Modalities
Diathermy is a physical agent used “most frequently” to increase temperature in deeply positioned tissues in order to (1) increase delivery of nutrients to the area by increasing blood flow, (2) diminish pain, or (3) increase the extensibility of tissues in musculoskeletal disorders. Diathermy utilizes non ionizing electromagnetic energy from the radio frequency portion of the electromagnetic spectrum.Three major types of diathermy (long wave, shortwave, and microwave) have been used by physical therapists to increase the temperature in tissues below the surface of the skin.Because diathermy is characterized by long wavelengths (approximately 3 cm to 300 m), theoretically its most potent thermal effect is not on skin and subcutaneous tissues but on the underlying musculature and associated connective tissues.
Indications for diathermy are deep muscle/joint pain; neuritis, rheumatoid and osteo- arthritis.
Contra indications for this modality are acute inflammatory/edema conditions, tendency to bleed, tumors, cancer, metal implants, pace maker or telemetry of any kind or near hearing aids and pregnancy.
Ultrasound, a form of acoustic energy, is often used by physical therapists because of its deep-heating and pain-relieving effects. The frequent use of this modality is probably related to its large number of indications and few contraindications or detrimental effects, its relative ease of application, and its clinically reported success.
Ultrasound waves have frequencies greater than 20,000Hz. The most common frequency used in therapeutic ultrasound is 1 MHz (1 million Hertz). Ultrasound units with a lower frequency (.87 MHz) are believed to be more effective in treating deeper tissues, whereas units with a higher frequency (3 MHz) are believed to be more effective in treating more superficial tissues. These units should not be confused with diagnostic units, which are used as an evaluative tool in medicine.
Ultrasound is delivered to the patient through the sound head or applicator. In most units, the applicator consists of a metal face plate with a piezoelectric crystal cemented to it. The crystal is a transducer, a device that converts one form of energy into another: in this case, from electrical energy to ultrasonic energy.
Phonophoresis is the use of ultrasound to drive medications into body tissues. Hydrocortisone, dexamethasone, and lidocaine are the medications commonly administered by phonophoresis. Ultrasound increases penetration and absorption of topical medications into deeper tissues. The technique for phonophoresis is the same as a routine ultrasound treatment except that the medication is placed on the skin immediately over the target structure. The hydrocortisone should be combined with an aqueous base to form the concentration and is prescribed by a physician and formulated by a pharmacist. Effective clinical results have been achieved using intensities in a mid to high range of 1W/sq cm. Additional studies are needed to document the most efficient mode of application for this noninvasive alternative to injection of medication into painful and inflamed structures.
Indications include, but are not limited to:
- Contracture: Joint capsules or adhesive scars
- Chronic arthritis
- Muscular problems
- Sympathetic nervous system disorders
- Plantar warts
- Open wounds
- Chronic systemic peripheral arterial disease
- Cardiac pacemakers
Electrical stimulation is used to assess and treat nerve and muscle tissues and to manage different neuromuscular conditions. For example, it is used to evaluate the integrity of neuromuscular tissues with tests such as nerve conduction velocity, electromyography, and the strength-duration test. Electrical stimulation is commonly used in physical therapy to treat neuromuscular conditions, enhance local circulation and tissue healing, decrease pain, and increase range of motion.
Types of Current Used in Physical Therapy
The two types of electrical current available for therapeutic purposes are direct current and alternating current. Direct current (DC) is the constant unidirectional flow of electricity. In DC circuits, the electrodes maintain their positive or negative polarity; therefore, when these electrodes are used to stimulate tissues, positive and negative fields will be established and maintained under the positive and the negative electrodes, respectively.
Direct current can induce chemical reactions in body tissues. The extent of such reactions depends on the duration and intensity of the current applied. Different chemical reactions occur at the positive and negative electrodes. The direct current output can be modified to deliver either a continuous or interrupted direct current mode. Therapeutically, continuous direct current is mainly used to induce chemical reactions and to transfer ions, a method called iontophoresis.
Interrupted direct current is used to stimulate motor, sensory, and autonomic nerves and muscle tissues. An interrupted direct current, which has a monophasic pulse of long duration can be produced easily by manually interrupting the direct current circuit with a “make or break” key. Interrupted direct current produced mechanically by the device at a preset rate may have an extremely brief duration. The so-called high-voltage pulse stimulator, deliver unidirectional, monophasic waveforms. The duration of each pulse is less than 100 microseconds, which is too short to induce a significant chemical reaction or to stimulate denervated muscle tissues. But such stimulators are used to stimulate intact neuromuscular tissues and other soft tissues.
Alternating current (AC) is a current that changes its direction of flow periodically; thus, its electrodes change polarity alternately. Unlike direct current, a positive and a negative field under each electrode are not maintained. Instead, the electrical fields change polarity (alternate) and the current rises to peak amplitude in the positive phase, falls back to the isoelectric point, then rises to the negative peak field and back to isoelectric point (or the zero point on a graphic representation of the given stimulus).
Transcutaneous Electrical Nerve Stimulation
Transutaneous electrical nerve stimulation (TENS) can be defined as the procedure of applying controlled, low-voltage electrical pulses to the nervous system by passing electricity through the skin via electrodes placed on the skin. The popularity of treating pain with electricity increased with the development of TENS. Originally, TENS was developed as a by-product of the Dorsal Column Electrical Stimulator, which was made to stimulate the nerves in the dorsal column directly as a means of controlling pain. Because this device had to be surgically implanted, finding a way to test the effects of such stimulation before implantation became important. Consequently, TENS was developed as a non-invasive technique based on the same principle as the Dorsal Column Electrical Stimulator. However, once TENS was used to screen patients for this stimulator, it was realized that, in many cases, treatment with TENS was sufficient to reduce the pain and the surgical procedure could be avoided. During the 1970s, the therapeutic use of TENS was refined and became a convenient and effective method of treating pain.
Because it is a safe and effective method of treating pain and has survived the scrutiny of the Food and Drug Administration (FDA), TENS is used after many surgical procedures, in obstetrics, and for acute and chronic pain caused by many different conditions. Its distribution and application to patients must be prescribed by a licensed physician.
Indications for electrical stimulation: peripheral nerve injuries or functional paralysis, pain due to muscle spasms, spasticity.
Contraindications include open wounds, implants meant to render a joint less flexible or fused, pacemakers, tumors, cancer, directly near the eye, pregnancy, severe sensory/circulatory impairments.
Iontophoresis is the treatment technique in which an electric current is used to drive ions of various medications through the skin and into underlying tissues. The ion to be applied must be available in its charged form and should be soluble in both water and lipids. The dosage must be carefully determined before the ion is applied. Dosage for the selected ionic concentration is expressed as a product of the intensity used in milliamperes and the duration of the treatment expressed in minutes.
Iontophoresis is usually used to reduce localized inflamed tissue such as tendinitis or bursitis, TMJ, trigger points and carpel tunnel.
Contraindications are similar to those of other forms of electrical stimulation.