INFRA RED RADIATION THERAPY - SUMMARY
It is a dry form of superficial heating modality and a useful method for superficial vigorous
heating of the human skin. When infrared modalities are applied to connective tissue or muscle
and soft tissue, they will cause a tissue temperature to increase.The primary physiologic effect of
heat is vasodilatation of capillaries with increased blood flow, increased metabolic activity, and
relaxation of muscle spasm. The infrared energies have a depth of penetration of less than 1 cm,
thus the physiologic effects are primarily superficial and directly affect the cutaneous blood
vessels and nerve receptors. The distance from the area to be treated to the lamp should be
adjusted according to treatment time. The standard formula is 20 inches (50 – 75 cms) distance =
20 minutes treatment time. Goggles should be provided to prevent the rays affecting the eyes.
After treatment, the skin surface should be checked.
IRR CLASSIFICATION: IR-A / Short IR: 700nm–1400nm, IR-B / Mid IR: 1400nm–3000nm, IR-C / Long IR: 3000
nm–1 mm
INDICATIONS
GENERAL & LOCAL CONTRAINDICATIONS
1. Subacute and chronic inflammatory conditions 1. Acute musculoskeletal conditions
2. Subacute or chronic pain
2. Impaired circulation & sensation
3. Subacute edema removal
3. Peripheral vascular disease
4. Decreased ROM / Joint Stiffness
4. Skin anesthesia
5. Resolution of swelling
5. Skin conditions–Fungus, Eczema,,
6. Myofascial trigger points
6. Deep X-ray therapy
7. Muscle guarding & Muscle spasm
7. Topical Creams & Oils
8. Subacute muscle strain
8. Superficial Metals
9. Subacute ligament sprain
9. Eyes
10. Subacute contusion
10. Malignant tissue
11. Tissue healing
11. Acute Infections
12. Sedation
12. Hyper Pyrexia
13. As a precursor to other treatment.
13. Severe Cardiac condition patients
PENETRATION DEPTHS: - In general all IRR types penetrate less than 1cm
 Short – 1- 3mm, Long – 0.5 – 1mm
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 1
SELECTION OF THE EQUIPMENT: If SEDATIVE EFFECTE is needed then – NON LUMINOUS IRR LAMP is selected –
Usually Sub acute stage
 If COUNTER IRRITATION is needed then – LUMINOUS IRR LAMP is chosen –
Usually Chronic stage pain
SETTING UP THE LAMP: Lamp position should be positioned perpendicular to the area of treatment with the
minimum / optimal distance to obtain MAXIMUM ABSORPTION.
CALCULATION OF DOSAGE;
 Sensory report of the patient – feel only a COMFORTABLE WARMTH. Adjusted by:
 Changing power output of the lamp / Type of the lamp / Distance of lamp to patient / Angle
of incidence / Time of exposure
WHEN IDEALLY TO SELECT IRR THERAPY:The infrared lamp should be used primarily when a patient cannot tolerate pressure from another
type of modality (e.g., hydrocollator packs). Caution must be exercised to avoid burns.
GUIDELINES FOR THE SAFE USE OF INFRA RED RADIATION THERAPY
 Receive the patient & read the case sheet
 Question the patient regarding any contra indications & about any previous thermotherapy
treatments
 Collect the essential / appropriate generator type of IRR & other materials needed for the
treatment
 Check the lamp & power cords
 Test the IRR lamp & perform the self-demonstration to the patient to gain the confidence
 Put the patient in a well relaxed & comfortably supported position
 Position yourself near to the patient & the lamp
 Prepare the specific area for the treatment
 Give adequate instruction & warning to the patient before to the start of treatment
 Place the IRR source in a appropriate / optimal distance usually – 50 – 75cms from the
treatment area.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 2
 Make necessary precautionary measures to protect the patient eyes & set the treatment
time usually for 15 – 20 min & Apply IRR therapy
 Complete the treatment & check for any adverse reactions in the treatment area
 Wind-up the materials
 Document / record all the details in the case sheet including the patient response to therapy
 Follow up the patient by providing him the next appointment.
ULTRAVIOLET RADIATION THERAPY - SUMMARY
The beneficial effects of UVR as a treatment modality are mediated by its limited absorption.
Ultraviolet radiation is absorbed within the first 1-2 mm of human skin and most of the
physiologic effects are superficial. Therefore, the most effective use of UVR therapy is in the
treatment of various skin disorders such as acne and psoriasis.
Exposure to UVR causes a photochemical reaction within living cells and can cause alterations of
DNA and cell proteins. The irradiation of human skin causes an acute inflammation that is
characterized by an erythema, increased pigmentation, and hyperplasia. The effects of long-term
exposure to UVR are premature aging of the skin and skin cancer. The eye is extremely sensitive
to UVR and will develop photokeratitis following exposure. Many types of equipment are
manufactured that produce UVR, but the majority used clinically are of the low- and highpressure mercury lamp variety.
TYPES OF UVR
 UVA (Long UV) – 400 – 315nm. {penetrates to dermis, Responsible for development of
slow natural tan}
 UVB (medium UV, erythemal UV) – 315 – 280nm. {Produces new pigment formation,
sunburn, Vitamin D synthesis. Responsible for inducing skin cancer}
 UVC (short UV, germicidal UV) – 280 – 100nm {Does not reach the surface of the earth}
INDICATIONS FOR UVR
 DERMATOLOGICAL CONDITIONS – Psoriasis, Acne, Sub acute & Chronic Eczema,
Vitiligo etc.
 Calcium / Phosphorus disease – Osteomalacia
 Non pulmonary tuberculosis
 Local Ulceration – Ulcers, Pressure sores, Surgical incision
 Upper respiratory condition management – Common Cold
 Counter Irritant Effect
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
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GENERAL & LOCAL CONTRAINDICATION OF UVR
 Pulmonary Tuberculosis
 Severe cardiac disturbances
 Systemic Lupus Erythematosis
 Severe Diabetes
 Dermatological Conditions
 Known Photosensitivity & Photosensitizing medication
 Deep x – Ray therapy
 Acute Febrile illness
 Recent skin grafts
 Porphyrias, Pellagra, Sarcoidosis, Xeroderma pigmentosum, Acute psoriasis
 Renal and hepatic insufficiencies, Hyperthyroidism, Generalized dermatitis
 Advanced arteriosclerosis, Acute eczema, Herpes simplex, Hypersensitivity to sunlight
PENETRATION OF THE UV RAYS
 UVA – Dermis level, UVB – Deep Epidermis
ULTRAVIOLET TREATMENT TECHNIQUES
Before operation of any UVR generator, therapists must thoroughly familiarize themselves with
the equipment; the operation manual must be understood and available if needed. Faulty operation
of the equipment can endanger both the patient and the operator. The lamp and reflector must be
kept clean by wiping with gauze and methyl alcohol or by following the manufacturer's
instructions. The quality of UVR is greatly diminished by dirty lamps and reflectors. The entire
device must be completely inspected prior to use to ensure safe operation.
DETERMINING THE MINIMAL ERYTHEMAL DOSE
The effectiveness of the apparatus must be determined before UVR therapy can begin. The lamps
in these devices deteriorate over time, and accumulation of dirt and other residues on the lamp and
reflector can also alter the effect of the UVR. Two lamps of the same model may have two
differing effects, depending on the age of the lamp and its condition. The effectiveness of the
lamp is assessed by determining the skin sensitivity to UVR of the patient to be treated. This
sensitivity is measured by the minimal erythemal dose. The minimal erythemal dose is the
exposure time needed to produce a faint erythema of the skin 24 hours after exposure. Prior to
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 4
testing, the patient should be questioned regarding photosensitizing drugs, and the area of skin to
be tested should be cleaned.
STEPS TO DETERMINE MINIMAL ERYTHEMAL DOSE (MED)
 The area chosen for the test is of importance. Because the patient is to inspect at regular
intervals a convenient, visible site is essential.
 It should be clear of skin disease.
 The FLEXOR SURFACE of the FOREARM is the most usual site.(Other sites are –
Abdomen, Medial aspect of arm / thigh)
 The selected site should be cleaned with soap & water to remove surface grease.
 Cover the patient other areas leaving only the forearm exposed to UVR.
 Three to Five holes of at least 2cm² & 1cm apart are cut in a piece of lint/paper/cardboard
is taken for irradiation of UVR along with a slide cover – to pull up to reveal one opening
at a time.
 This cutting is fixed to the forearm with adhesive plaster.
 The cuttings are of different sizes & shapes in-order to make IDENTIFICATION OF THE
ERYTHEMA EASIER for the patient.
 Allow the lamp to warm up according to the manufacturer instructions.
 Place the lamp PERPENDICULAR to the area being tested (Forearm) & a DISTANCE of
60 to 90cms from the site.
 Expose the 1st opening for 30sec, then expose the
2nd opening for another 30sec & go
on till the last opening
 So the 1st opening would receive the longest exposure time & the last opening would
receive the least amount of exposure time.
 Switch off the lamp
 Instruct the patient to MONITOR the forearm every 2hrs & note which opening or shape
appeared pink / red first & when it faded / disappeared.
 The patient is also given a card / chart similar to the opening to make a note.
MINIMAL ERYTHEMAL DOSE
 It is a slight reddening (erythema) of the skin which takes from 6 – 8hrs to develop &
which is still just visible at 24hrs.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
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DESCRIPTION OF DEGREES OF ERYTHEMA
Degree
Erythema
of
Latent
Appearance color
period
Duration of
Skin
Skin
Desquamation
Relation to
Erythema
Oedema
discomfort
of skin
E1 Dose
In HRS
E1
6-8
Mildly pink
<24hrs
None
None
None
E1
E2
4-6
Definite Pink Red.
2 Days
None
Slight
Powdery
2.5% of E1
Blanches
on
Soreness,
Pressure
E3
2-4
Very red, Does not
Irritation
3-5 Days
Some
Hot & Painful
In thin Sheets
5% of E1
A Week
Blister
Very Painful
Thick Sheets
10% of E1
blanch on pressure
E4
<2
Angry Red
DOSAGE - The quantity of UVR energy applied to unit area of the skin.(Depends on);
 The output of lamp – Make, Type, Aging
 Distance between the lamp & the skin – Inverse square law
 Angle at which radiations fall on the skin – cosine law
 Time for which radiations are applied
 The sensitivity of the skin
GENERAL GUIDLINE FOR THE CALCULATION OF DOSAGE
 E1/MED is the basic of UV calculation which is determined for each individual patient by
performing a skin test. From this point all other doses of UVR can be calculated.
 E2 = 2½ x E1
 E3 = 5 x E1
 E4 = 10 x E1
GENERAL RECOMMENDED DOSAGE FOR CERTAIN CONDITIONS: General irradiation for vitamin D synthesis – E1 Dose
 Acne vulgaris – E2 Dose
 Pressure sores – E2 / E3 Dose
 Counter irritation / Chronic infected open wounds – E4 Dose
GENERAL GUIDLINE FOR THE PROGRESSION OF DOSAGE:
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 6
 To repeat an E1 25% of the preceding E1 dose is added
 To repeat an E2 50% of the preceding E2 dose is added
 To repeat an E3 75% of the preceding E3 dose is added
 To repeat an E4 100% of the preceding E4 dose is added
GENERAL GUIDLINE FOR THE SELECTION OF DIFFERENT DOSAGE LEVEL
 An E1/MED – Given to the total body area (Whole body)
 An E2 - May not be given to up to 20% of total body area
 An E3 – May not be given to up to 250cm² of normal skin
 An E4 – May only be given to an area up to 25cm² of normal skin.
GENERAL GUIDLINE FOR THE FREQUENCY OF UVR TREATMENT
 An E1 / MED may be given DAILY
 An E2 – Should be given every second day
 An E3 – Should be given every 3 or 4th day (Twice Weekly)
 An E4 – may only be given once a week or even once a fortnight.
 N.B. when treating non-skin areas such as pressure areas or ulcers, all doses may be given
daily as there is no erythema reaction produced.
PUVA THERAPY
This is a treatment for psoriasis that consists of ingestion of oral methoxsalen, a psoralen, and
exposure of the affected site to a UV-A light source. The methoxsalen increases the patient's
sensitivity to UVR, and in the presence of UV-A it binds with DNA and inhibits DNA synthesis.
Unfortunately, several studies point to an increased risk of developing skin cancer following
PUVA therapy, and problems with the safety of the UV-A sources have been uncovered. Still, in
selected cases PUVA therapy is considered by the American Academy of Dermatology to be safe,
but its use should be limited to physicians with training in photochemotherapy.
WHEN IDEALLY TO SELECT UVR - Usually for dermatological conditions & ulcers
GUIDELINES FOR THE SAFE USE OF ULTRAVIOLET RADIATION THERAPY
 Receive the patient & read the case sheet
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 7
 Question the patient regarding any contra indications & about any previous UVR
treatments
 Collect the essential / appropriate generator type of UVR & other materials needed for the
treatment
 Check the lamp & power cords
 Test the UVR lamp & perform the self-demonstration to the patient to gain the confidence
 Put the patient in a relaxed & well comfortably supported position
 Position yourself near to the patient & the lamp
 Prepare the specific area for the treatment
 Give adequate instruction & warning to the patient before to the start of treatment
 Place the UVR source in a appropriate / optimal distance usually – 60 – 90cms from the
treatment area. Make necessary precautionary measures to protect the patient eyes & set
the treatment time according to the MED / E1 Dose & Apply UVR therapy
 Complete the treatment & check for any adverse reactions in the treatment area
 Wind-up the materials
 Document / record all the details in the case sheet including the patient response to therapy
 Follow up the patient by providing him the next appointment.
SHORTWAVE DIATHERMY - SUMMARY
Diathermy is the application of high-frequency electromagnetic energy with 27.12 MHz at
wavelength of 11 M that is primarily used to generate heat (Deep) in body tissues. Shortwave
diathermy may be continuous or pulsed. The physiologic effects of continuous shortwave is
primarily thermal, resulting from high-frequency vibration of molecules. Pulsed shortwave
diathermy has been used for its nonthermal effects in the treatment of soft-tissue injuries and
wounds. A shortwave diathermy unit that generates a high-frequency electrical current will
produce both an electrical field and a magnetic field in the tissues. The ratio of the electrical field
to the magnetic field depends on the characteristics of the different units as well as on the
characteristics of electrodes or applicators.
The capacitance technique, using capacitor electrodes (air space plates and pad electrodes),
creates a strong electrical field that is essentially the lines of force exerted on charged ions by the
electrodes that cause charged particles to move from one pole to the other.
The inductance technique, using induction electrodes (cable electrodes and drum electrodes),
creates a strong magnetic field when current is passed through a coiled cable. It may affect
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 8
surrounding tissues by inducing localized secondary currents, called eddy currents, within the
tissues.
Pulsed diathermy is created by simply interrupting the output of continuous shortwave diathermy
at consistent intervals. Generators that deliver pulsed shortwave diathermy typically use a drum
type of electrode to induce energy in the treatment area via the production of a magnetic field.
Effective treatments using the diathermies require practice in application and adjustment of
techniques to the individual patient. Four advantages for the use of diathermy over ultrasound are
larger heating area, more uniform heating, longer stretching window, and more clinician freedom.
TYPES OF ELECTRODES USED IN SWD
Flexible pads
Space plates
Coil
The Monode
The Diplode
TREATMENT METHODS - Selection of Appropriate methods can Influence the Treatment
 Capacitor (Condenser) field Method
 Inductive field (Cable) Method
METHODS OF PLACEMENT OF ELECTRODES – CAPACITOR METHOD
COPLANAR
CONTRAPLANAR
CROSSFIRE
MONOPOLAR
METHODS OF PLACEMENT OF ELECTRODES - INDUCTIVE FIELD (CABLE)
Wraparound Coils
Pancake Coils
FACTORS INFLUENCE FIELD DISTRIBUTION IN S.W.D
1. Spacing – provided by: Wrapping flexible pads in towel.
 Flat felt spacing pads between pad electrode and skin.
 Air when using space plates.
 Normal spacing even field distribution.
 Increased spacing deep field concentration.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 9
 Decreased spacing superficial concentration.
2. Electrode size and Metal
DOSAGE GUIDELINES - Patient sensation provides the basis for recommendations of
continuous shortwave diathermy dosage and thus varies considerably with different patients. The
following dosage guidelines have been recommended.
 Dose I (lowest): No sensation of heat
 Dose II (low): Mild heating sensation
 Dose III (medium): Moderate (pleasant) heating sensation
 Dose IV (heavy): Vigorous heating that is tolerable below the pain threshold
INDICATIONS OF SWD
 Disorders of Musculoskeletal System;
( Sprain, Strain, Muscle & Tendon tear, Capsule lesion, Joint stiffness, Hematomas)
 Sub acute & Chronic Inflammatory Conditions;
(Tenosynovitis, Bursitis, Synovitis, Sinusitis, Dysmenorrhoea, Fibrositis, Myositis)
GENERAL & LOCAL CONTRAINDICATIONS
 Metal implants or metal jewelry (be aware of body piercings) – Concentration of the field.
 Cardiac pacemakers – Interference with function
 Ischemic areas – The inability of the circulation to disperse heat could result in high
temperature – Burns.
 Peripheral vascular disease - DVT
 Perspiration and moist dressings: The water collects and concentrates the heat.
 Tendency to hemorrhage, including menstruation – Increase vasodilatation, prolong
hemorrhage.
 Pregnancy – Miscarriage
 Hyperpyrexia
 Sensory loss / Impaired thermal sensation
 Cancer / Malignant tissues – Accelerate the rate of growth & Metastasis
 Active T.B – Increase the rate of development of the infection.
 Recent Radiotherapy – Skin sensation & Circulation may be decreased.
 Dermatological Conditions – Will exacerbate
 Severe Cardiac conditions – Greater demand of Cardiac output.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 10
 Areas of particular sensitivity:
 Epiphysis plates in children
 The genitals
 Sites of infection
 The abdomen with an implanted intrauterine device (IUD)
 The eyes and face & Application through the skull
GENERAL GUIDELINES - APPLICATION OF SWD (CONTINUOUS & PULSED TYPE)
1- Shortwave machine with chosen electrodes and its test tube to ensure the machine is working.
2- Test tubes for skin test.
3- Cotton towels or felt pads for spacing.
4- Ensure that there are no contraindications for SW application.
5- Put the patient in a comfortable position and well support, allow the area to be treated to be
completely uncovered.
6- Inspect the area to be treated.
7- Ensure there is no metal (jewellery or hairpin) within 300mm of treatment area.
8- Explain the procedure and feeling to the patient.
9- If using flexible pad electrodes, wrap them in several layers of towelling or place them between
felt pads to ensure the required amount of spacing.
10- If using space electrodes adjust the distance according to the concentration needed.
11-Instruct the patient not to move during treatment and warn her/him from uncomfortable heat
feeling.
12- If the machine has a patient safety switch instruct the patient to switch the machine off if he
feel more heat.
13- Check the machine controls at the zero position, then switch the power on.
14- Switch the intensity on and wait 2-3 minutes on the minimum intensity and ask the patient
about her/his feeling, then adjust the timer to the required treatment time.
15- After treatment time has finished, turn the intensity switch to zero and remove the electrodes.
16-Inspect the area after treatment and ask the patient to stay few minutes for rest and to regain to
normal temperature.
WHEN IDEALLY TO SELECT SWD
 If for any reason the skin or some underlying soft tissue is very tender and will not tolerate
the loading of a moist heat pack or pressure from an ultrasound transducer, then diathermy
should be used.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 11
 When the treatment goal is to increase tissue temperatures in a large area (i.e., throughout
the entire shoulder girdle, in the low back region), the diathermies should be used.
 In areas where subcutaneous fat is thick and deep heating is required, the induction
technique using either cable or drum electrodes should be used to minimize heating of the
subcutaneous fat layer. The capacitance technique is more likely to selectively heat more
superficial subcutaneous fat.
 Induction method - When The Treatment Goal Is To Increase Tissue Temperatures Over A
Large Area
 If the goal of treatment is to increase tissue extensibility & the limitation is primarily to
capsular tightness, then capacitor field method of SWD is the more appropriate choice.
ULTRASOUND THERAPY- SUMMARY
Ultrasound is defined as inaudible, acoustic vibrations of high frequency that may produce either
thermal or nonthermal physiologic effects. Ultrasound travels through soft tissue as a longitudinal
wave at a therapeutic frequency of either 1 or 3 MHz.
As the ultrasound wave is transmitted through the various tissues, there will be attenuation or a
decrease in energy intensity owing to either absorption of energy by the tissues or dispersion and
scattering of the sound wave.
Ultrasound is produced by a piezoelectric crystal within the transducer that converts electrical
energy to acoustic energy through mechanical deformation via the piezoelectric effect. Ultrasound
energy travels within the tissues as a highly focused collimated beam with a nonuniform intensity
distribution.
Although continuous ultrasound is most commonly used when the desired effect is to produce
thermal effects, pulsed ultrasound or continuous ultrasound at a low intensity will produce
nonthermal or mechanical effects. Therapeutic ultrasound when applied to biologic tissue may
induce clinically significant responses in cells, tissues, and organs through both thermal effects,
which produce a tissue temperature increase, and nonthermal effects, which include cavitation and
microstreaming.
Phonophoresis is a technique in which ultrasound is used to drive molecules of a topically applied
medication, usually either anti-inflammatories or analgesics, into the tissues.
In a clinical setting, ultrasound is frequently used in combination with other modalities, including
hot packs, cold packs, and electrical stimulating currents, to produce specific treatment effects.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 12
For ultrasound to be effective, the therapist must pay particular attention to correct parameters
such as intensity, frequency, duration, and treatment size. Ultrasound is one of the most widely
used modalities in physical therapy
BIOPHYICAL PROPERTIES OF ULTRASOUND
 Propagation of a wave
 Absorption & Penetration
 Reflection & Refraction
 Attenuation & Scattering
THERAPEUTIC TRANSDUCER
 It is available in a variety of sizes from 1cm² to 10cm²
 The 5cm² is the most frequently clinically used ultrasound transducer.
Transducer Head
FREQUENCY OF ULTRASOUND
 Determined by number of times crystal deformed/sec.
 2 most common frequency utilized in U.S.
◦
1.0 MHz
◦
3.0 MHz
 Determines depth of penetration.
 Inverse relationship between frequency and depth of penetration
 Penetrating depths:
◦
1.0 MHz: 2-5 cm
◦
3.0 MHz: 1-2 cm
 Absorption rate increases with higher frequency
ULTRASOUND INTENSITY (SOUND PRESSURE)
 Spatial Peak Intensity (SPI) - highest intensity within beam
 Beam Non-uniformity Ratio(BNR) - can be thought of as “SPI/SAI”
 The lower the BNR the more even the distribution of sound energy
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 13
 BNR should always be between 2 and 6
 Ultrasound Intensity - “pressure” of beam
 Rate sound energy delivered ( watts / cm 2 )
 Spatial Average Intensity (SAI) - related to each machine
 Energy (watts) / area (cm 2) of transducer
 Normal SAI = .25 - 2 watts / cm 2
 Maximal SAI = 3 watts / cm 2
 Intensities > 10 watts / cm 2 : destroy tissues
BNR & ERA
Beam nonuniformity ratio (BNR) Indicates the amount of variability of intensity within the
ultrasound beam and is determined by the maximal point intensity of the transducer to the average
intensity across the transducer surface. Effective radiating area (ERA) The total area of the
surface of the transducer that actually produces the sound wave.
TYPES / MODES OF ULTRASOUND BEAM
 Continuous Wave - no interruption of beam: best for maximum heat buildup – Usually
selected for sub-acute & chronic conditions
 Pulsed Wave - intermittent “on-off” beam modulation builds up less heat in tissues , used
for post - acute injuries
COUPLING MEDIUM
 COUPLANT:- To establish the transmission of ultrasound energy to the tissues depends
on having a couplant. The space between the transducer head & the patient is filled with a
layer of COUPLING MEDIUM usually the ultrasonic gel.
COUPLING MEDIUM IN GENERAL - Substances used to conduct US
 US gel and gel pads—effective conductors
 Mineral oil—poor
 Lotions—poor
 Water—may attenuate as much as 66% of sound waves; not very good
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 14
Non-thermal Effects of Ultrasound
Cavitation
gas buble expansion
gas buble compression
Microstreaming
bubble rotation &
associated fluid
movement along
cell membranes
INDICATIONS
 Acute and postacute conditions (ultra-sound with nonthermal effects)
 Soft tissue healing and repair Scar tissue Joint contracture
 Decrease chronic inflammation
 Increase extensibility of collagen
 Decrease muscle spasms
 Pain modulation
 Increase in protein synthesis
 Tissue regeneration
 Decrease pain of neuromas
 Decrease joint adhesions
 Acute and chronic treatment of soft tissue dysfunction, that is, strains, sprains, contusions
with associated symptoms of pain, and muscular spasm.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 15
 Ultrasound can also be employed to percutaneously deliver selected medications to areas
of inflammation.
 Bone healing & Repair of nonunion fractures
 Inflammation associated with myositis ossificans Plantar warts Myofascial trigger points
GENERAL & LOCAL CONTRAINDICATIONS
 Hemorrhage
 Infection
 Thrombophlebitis
 Suspected malignancy
 Impaired circulation or sensation
 Stress fracture sites
 Epiphyseal growth plates
 Over the Eyes, Heart, Spine, or genitals
 Not over reproductive organs
 Not over eyes, heart, spinal cord, or cervical/stellate ganglia
 Not over cemented joint prostheses
 Pregnancy
CONTINUOUS VS PULSED
DUTY CYCLE
 The percentage of time that ultrasound is being generated (pulse duration) over one pulse
period is referred to as the duty cycle or as the mark to space ratio.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 16
TISSUE STATE VS INTENSITY
Tissue State
Intensity required at the lesion (W/cm2)
Acute state
0.1 - 0.3 (W/cm2)
Sub-Acute state
0.2 - 0.5 (W/cm2)
Chronic state
0.3 - 0.8 (W/cm2)
METHODS ADAPTED FOR THE EFFECTIVE TREATMENT IN ULTRASOUND
THERAPY
 Direct contact method – Usually selected to treat even surface like back, thigh etc.
 Underwater / Immersion method - 40-60% less heating than gel – Usually for treating
uneven surface like distal extremities.
 Balloon / Bladder method - 50% energy loss in transmission - Usually for treating uneven
surface like knee, shoulder etc.
 Gel pads - Equivalent to US gel
STROKING TYPES USED IN ULTRASOUND THERAPY
 Overlapping circular – clockwise / anti clockwise stroking
 Transverse stroking
 Figure of eight stroking
CLINICAL APPLICATIONS
 Soft tissue healing & repair - pulsed ultrasound at 0.5 W/cm2 with a duty cycle of 20
percent for 5 minutes or continuous ultrasound at 0.1 W/cm2.
 Plantar Warts - 0.6 W/cm2 for 7-15 min.
 Scar tissue - 1.2 – 2.0 W/cm² at 100% duty cycle.
 In the general condition (tendinitis, bursitis) of the shoulder – 100% duty cycle at 1.0-2.0
W/cm2.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 17
 Chronic Inflammation - Pulsed US has been shown to be effective with  pain &  ROM
 1.0 to 2.0 W/cm2 at 20% duty cycle
 Bone Healing – Pulsed US has been shown to accelerate fracture repair
 0.5 W/cm2 at 20% duty cycle for 5 min., 4x/week
 Caution over epiphysis – may cause premature closure
TREATMENT DURATION & AREA - Length of time depends on the
 Size of area
 Output intensity
 Goals of treatment
 Frequency
 Area should be no larger than 2-3 times the surface area of the sound head ERA
 If the area is large, it can be divided into smaller treatment zones
 When vigorous heating is desired, duration should be 10-12 min for 1 MHz & 3-4 min for
3 MHz
 Generally a 10-14 day treatment period is essential
WHEN IDEALLY TO SELECT ULTRASOUND THERAPY
It has traditionally been classified as a "deep heating modality" and has been used primarily for
the purpose of elevating tissue temperatures especially in smaller treatment areas
GUIDELINES FOR THE SAFE USE OF ULTRASOUND EQUIPMENT
The following treatment guidelines will help to ensure patient safety:
 Question patient (General contraindications/previous treatments).
 Position patient (comfort, modesty).
 Inspect part to be treated (check for rashes, infections, or open wounds – Local
Contraindications).
 Obtain appropriate soundhead size.
 Determine ultrasound frequency (1 MHz for deep, 3 MHz for superficial).
 Set duty cycle (choose either continuous or pulsed setting).
 Apply couplant to area.
 Set treatment duration (vigorous heat = 10-12 min at 1 MHz and 3-4 min at 3 MHz).
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 18
 Maintain contact between the skin and the applicator (move at a rate of 4 cm/sec, for 2
ERA).
 Adjust intensity to perception of heat. (If this gets too hot, turn down the intensity or move
applicator slightly faster.)
 If goal is increased joint ROM, put part on stretch (for the last 2-3 min of insonation, and
maintain stretch or friction massage 2-5 min after termination of treatment).
 Terminate treatment. (Turn all dials to zero, clean gel from unit.)
 Assess treatment efficacy. (Inspect area, feedback from client.)
 Record treatment parameters.
 Note: Ultrasound units should be recalibrated every 6-12 months, depending on the
frequency of use.
LASER THERAPY - SUMMARY
LASER is an acronym that stands for light amplification of stimulated emissions of radiation.
Light is transmitted through space in waves and is comprised of photons emitted at distinct energy
levels. An atom is excited when energy is applied and raises an orbiting electron to a higher orbit.
When the electron returns to its original orbit, it releases energy in the form of a photon, a process
called spontaneous emission. Stimulated emission occurs when the photon is released from an
excited atom and promotes the release of an identical photon to be released from a similarly
excited atom. For lasers to operate, a medium of excited atoms must be generated. This is termed
population inversion and results when an external energy source (pumping device) is applied to
the medium. Laser can be thermal (hot) or nonthermal (low power, soft, or cold).
The proposed therapeutic applications of lasers in physical medicine include acceleration of
collagen synthesis, decrease in microorganisms, increase in vascularization, and reduction of pain
and inflammation.
PROPERTIES / CHARACTERISTICS OF LASER
 Coherence - In phase
 Monochromaticity - Single color or Single wavelength
 Collimation - Minimal divergence
THE LASER COMMONLY USED IN PHYSIOTHERAPY IS
 Helium – neon laser (HeNe) - 632.8nm – Visible red beam
 Gallium Aluminium Arsenide ( GaAlAs) – 904nm – Invisible
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 19
CLASSIFICATION OF LASERS
RANGE OF POWER
LOW POWER
MID POWER
USAGE
EFFECTS
1. Blackboard pointer
No effect on Eye or
2. Supermarket barcode reader
skin
Models up to 50mW mean power(3A – 3B, Safe on skin & Not in
LLLT)
Used
therapeutically
for
the eye
physiotherapy treatment
HIGH POWER
Surgical Destructive
Not safe on skin & eye
TYPE OF LASERS
LASER TYPES
WAVELENGTH
RADIATION
RUBY
694.3nm
Red Light
HELIUM - NEON
632.8nm
Red Light
650 – 904nm
Red Light - Infrared
DIODE S
DEPTH OF PENETRATION
 Helium – Neon Laser – up to EPIDERMIS – a direct penetration of 2-5 mm and an
indirect penetration of 10-15 mm
 GaAlAs – up to EPIDERMIS & DERMIS - a direct penetration of 1-2 cm and an indirect
penetration to 5 cm.
INTENSIY OF LASER
 The intensity of laser used in physiotherapy treatment range from 1mWcm¯² to
50mWcm¯².
 It is relatively very low power & Intensity.
 The beam diameter is about 3mm which is used clinically.
INDICATIONS OF LASER
 Musculoskeletal Conditions
 Swelling of Joints
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 20
 Neurogenic pain states
 Myofascial pain
 Post traumatic joint disorders & Burns
 Facilitate wound healing
 Pain reduction
 Increasing the tensile strength of a scar & Decreasing scar tissue
 Decreasing inflammation
 Bone healing and fracture consolidation
CONTRAINDICATION OF LASER
 Over cancerous tissue
 Pregnant Uterus
 Hemorrhage
 Infected tissue
 Epileptic
 Cardiac patients
 Pacemakers
 Directly into the eyes
ENERGY DENSITY/RADIANT EXPOSURE
 1. The amount of energy delivered to the patient is measured in JOULES PER
CENTIMETER SQUARE. J/Cm². The dosage is dependent on (1) the output of the laser
in mW, (2) the time of exposure in seconds, and (3) the beam surface area of the laser in
cm2.
 Average power
 The usual ranges are from 1 to 10J/cm²
 Dose as low as 0.5 J/cm²
 Dose as high up to 32 J/cm²
 The therapeutic laser range from 0.5J/cm² - 4J/cm²
 It is generally recommended that the LOW PULSE FREQUENCIES & LONG PULSE
DURATIONS for – ACUTE CONDITION - from 0.05 to 0.5 J/cm2
 HIGHER PULSE FREQUENCY & SHORT PULSE DURATION for
– CHRONIC
CONDITIONS - from 0.5 to 3 J/cm2
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 21
The HeNe laser has a 1.0-mW average power output at the fiber tip and is delivered in the
continuous wave mode. The GaAs laser has an output of 2 W but has only a 0.4-mW average
power when pulsed at its maximum rate of 1000 Hz. The frequency of the GaAs is variable, and
the clinician may choose a pulse rate of 1-1000 Hz, each with a pulse width of 200 nsec (nsec =
10-9) and. The pulsed modes drastically reduce the amount of energy emitted from the laser.
For general application, only the treatment time and the pulse rate vary. For research purposes, the
investigator should measure the exact energy density emitted from the applicator before the
treatments.
PARAMETERS OF LOW-OUTPUT LASERS
Parameters
Helium Neon (HeNe)
Gallium Arsenide (GaAs)
Laser type
Gas
Semiconductor
Wavelength
632.8 nm
904 nm
Pulse rate
Continuous wave
1-1000 Hz
Pulse width
Continuous wave
200 nsec
Peak power
3 mW
2W
Average power
1.0 mW
0.04-0.4 mW
Beam area
0.01 cm
0.07 cm
Copied with permission from Physio Technology
THE TECHNIQUE / METHODS OF LASER APPLICATION
 Direct contact method / Gridding method - Laser aperture should be perpendicular to the
surface. Lase each square centimeter of the injured area for the specified time. The
aperture should be in light contact with the skin. It is the the most frequently utilized
method of application.
 Scanning / Non - contact method – When skin contact cannot be maintained, the remote
should be held still in the center of the square centimeter grid at a distance of less than 1
cm. If using the HeNe laser, the red beam should fill a 1-cm2 grid.
 The wanding technique - is not recommended because of irregularities in the dosages.
 Trigger / Acupuncture point method – usually for painful conditions
SUGGESTED TREATMENT APPLICATIONS
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 22
Application
Laser Type
Energy Density
Superficial
HeNe
1-3 J/cm2
Deep
GaAs
1-2 J/cm2
Acute
GaAs
0.1-0.2 J/cm2
Sub-acute
GaAs
0.2-0.5 J/cm2
Acute
HeNe
0.5-1 J/cm2
Chronic
HeNe
4 J/cm2
Acute
GaAs
0.05-0.1 J/cm2
Chronic
GaAs
0.5-1 J/cm2
GaAs
0.5-1 J/cm2
Trigger point
Edema reduction
Wound healing (superficial tissues)
Wound healing (deep tissues)
Scar tissue
Copied with permission from Physio Technology.
CLINICAL CONSIDERATIONS
 Tensile strength - HeNe laser of doses ranging from 1.1 to 2.2 J/cm2 elicited positive
results when lased either twice a day or on alternate days.
 Immunologic responses - faster healing and cleaner wounds when subjected to GaAs laser
treatment three times per week.
 Inflammation - treatments with HeNe laser at 1 J/cm² for 4 days reflect an accelerated
resolution of the acute inflammatory process.
WHEN IDEALLY TO SELECT LASER THERAPY
 Its applications can include wound healing properties on lacerations, abrasions, or
infections - to have faster healing rates with less pain.
 In humans, improvement of nonhealing wounds indicates promising possibilities for
treatment with lasers.
 To date the low-level laser is indicated for adjuncted use in the temporary relief of hand
and wrist pain associated with carpal tunnel syndrome.
GUIDELINES FOR THE SAFE USE OF LASER THERAPY
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 23
 Receive the patient & read the case sheet
 Question the patient regarding any contra indications & about any previous LASER
therapy
 Collect the essential / appropriate generator type of LASER & other materials needed for
the treatment
 Check the lamp & power cords
 Test the LASER & perform the self-demonstration to the patient to gain the confidence
 Put the patient in a relaxed & well comfortably supported position
 Position yourself near to the patient & the LASER equipment
 Prepare the specific area for the treatment
 Give adequate instruction & warning to the patient before to the start of treatment
 Choose appropriate method of treatment
 Make necessary precautionary measures to protect the patient eyes & set the treatment
time
 Complete the treatment & check for any adverse reactions in the treatment area
 Wind-up the materials
 Document / record all the details in the case sheet including the patient response to therapy
 Follow up the patient by providing him the next appointment.
MICROWAVE DIATHERMY - SUMMARY
Microwave diathermy has two FCC-assigned frequencies, 2456 and 915 MHz. Microwave has a
much higher frequency and a shorter wavelength than shortwave diathermy. Microwave
diathermy units generate a strong electrical field and relatively little magnetic field.
With appropriate setup of the microwave diathermy unit, less than 10 percent of the energy is lost
from the machine as it is applied to the patient. The microwave applicator beams energy toward
the patient, creating the potential for much of the energy to be reflected.
Heating is caused by the intramolecular vibration of molecules that are high in polarity. If
subcutaneous fat is greater than 1 cm, the fat temperature will rise to a level that is too
uncomfortable before there is a tissue temperature rise in the deeper tissues. This is less of a
problem if the microwave diathermy is of the frequency of 915 MHz. However, there are very few
commercial units operating on that frequency. Almost all of the older units have the higher
frequency of 2456 MHz. If the subcutaneous fat is 0.5 cm or less, microwave diathermy can
penetrate and cause a tissue temperature rise up to 5 cm deep in the tissue. Bone tends to absorb
more shortwave and microwave energy than any type of soft tissue.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 24
MICROWAVE DIATHERMY APPLICATORS

Circular Shaped Applicators 4” or 6” Maximum Temperature At Periphery

Rectangular Shaped Applicators 4.5 x 5” or 5 x 21” Maximum Temperature At Center
INDICATIONS
 Postacute musculoskeletal injuries
 Increased blood flow Vasodilation
 Increased metabolism
 Changes in some enzyme reactions
 Increased collagen extensibility
 Decreased joint stiffness & Improved joint range of motion
 Muscle relaxation & Muscle guarding
 Increased pain threshold
 Enhanced recovery from injury
 Joint contractures
 Myofascial trigger points
 Increased circulation
 Reduced subacute and chronic pain
 Resorption of hematoma
 Increased nerve growth and repair
GENERAL& LOCAL CONTRAINDICATIONS
 Acute traumatic musculoskeletal injuries
 Acute inflammatory conditions
 Areas with ischemia
 Areas of reduced sensitivity to temperature or pain
 Fluid-filled areas or organs
 Joint effusion - Synovitis
 Eyes Contact lenses
 Moist wound dressings
 Malignancies
 Infection Pelvic area during menstruation
 Testes
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 25
 Pregnancy
 Epiphyseal plates in adolescents
 Metal implants
 Unshielded cardic pacemakers
 Intrauterine devices
 Watches or jewelry
MICROWAVE DIATHERMY TREATMENT TECHNIQUE

Microwave diathermy units require a period of time to warm up. This is normally built
into the circuitry so that the unit power cannot be turned on until the unit is sufficiently
warmed. This warm-up time is a good time for the therapist to position the director and the
patient.

The director should be located so that the maximum amount of energy will be penetrating
at a right angle or perpendicular to the skin. Any angle greater or less than perpendicular
will create reflection of the energy and significant loss of absorption (cosine law).
MICROWAVE DIATHERMY - AVAILABLE TREATMENT TECHNIQUES
 Direct contact method
 Non-Contact method
WHEN IDEALLY TO SELECT MICROWAVE DIATHERMY
 Microwave diathermy is best used to treat conditions that exist in those areas of the body
that are covered with low subcutaneous fat content.
 The tendons of the foot, hand, and wrist are well treated, as are the acromioclavicular and
sternoclavicular joints, the patellar tendon, the distal tendons of the hamstrings, the
Achilles tendon, and the costochondral joints and sacroiliac joints in lean individuals.
GENERAL GUIDELINES - APPLICATION OF MWD
1- MWD with chosen electrodes and its test tube to ensure the machine is working.
2- Test tubes for skin test.
3- Cotton towels or felt pads for spacing.
4- Ensure that there are no contraindications for MWD application.
5- Put the patient in a comfortable position and well support, allow the area to be treated to be
completely uncovered.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 26
6- Inspect the area to be treated.
7- Ensure there is no metal (jewellery or hairpin) within 300mm of treatment area.
8- Explain the procedure and feeling to the patient.
9- Instruct the patient not to move during treatment and warn her/him from uncomfortable heat
feeling.
10- If the machine has a patient safety switch instruct the patient to switch the machine off if he
feel more heat.
11- Check the machine controls at the zero position, then switch the power on.
12- Switch the intensity on and wait 2-3 minutes on the minimum intensity and ask the patient
about her/his feeling, then adjust the timer to the required treatment time.
13- After treatment time has finished, turn the intensity switch to zero and remove the electrodes.
14-Inspect the area after treatment and ask the patient to stay few minutes for rest and to regain to
normal temperature.
HYDROCOLLATOR / HOT PACK / MOIST HEAT THERAPY – SUMMARY
The use of moist heat as a therapeutic agent is one of the oldest forms of medicine. Commercial
hot packs are one of the most common ways to deliver superficial moist heat.
THE HYDROCOLLATOR UNIT
 The hydro-collator unit is a stainless steel tank in which silica gel packs or BENTONITE
crystal packs are heated.
 The capacities of the machines vary, and all units have insulated bases, the larger
machines being insulated with fiberglass.
 The units contain a wire rack which acts as divider for the packs and prevents contact of
packs with the bottom of the tank.
 These packs are stored in thermostatically controlled and maintain water in the unit at a
temperature between 70°C and 80°C.
 Packs are removed by tongs or scissor handles.
 It can be left on continuously as long as there is enough water in the tank.
THE HYDRO COLLATOR PACK
 A hydrocollator pack is good in any situation that requires penetrating heat.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 27
 A hydro collator pack is a fabric envelope containing silica gel.
 The main property of the gel is its capability to absorb many times its own volume of
water & provides a considerable store (retain) of heat energy for more time
 These packs are heated in a hydro-collator unit.
 It give moist heat for 30 to 40 minutes
 Packs come in various sizes and shapes
 A special collar pattern pack for the neck is usually available.
 The packs last about six months.
 When they begin to wear out the filler leaks out and makes the water cloudy; they should
then be replaced.
THE PACKS ARE WRAPPED IN
 Turkish towels – 6- 8 layers of toweling
 Special / commercial terry cloth blankets
 Large packs may be wrapped in bath blankets.
 The purpose of wrapping the pack is to provide THERMAL INSULATION, So that the
pack is at above 75˚C & the skin temperature does not rise above 42˚C or so).
THE APPLICATION OF HYDROCOLLATOR PACK
 The pack is applied to the body after being wrapped adequately in toweling or blankets.
Care must be taken to have a layer of toweling and to avoid excessive pressure by weight
being placed on bony points.
 The part selected to be treated must be able to tolerate the pressure of the pack
(approximately 500 to 800 grams) and to tolerate a 7° C to 10°C rise in temperature.
 The temperature of the wrapped pack should not exceed the 44˚C
 Monitor the initial response from the patient to treatment during the first 5 to 10 min by
asking the patient for feedback & by visually inspecting the skin for any adverse reactions
 If necessary, adjust the layers of toweling.
 During the treatment maintain the position of hot pack & ensure that it does not
exacerbate pain, produce discomfort or occlude circulation.
 But after 10 min of the treatment the patient may regard the pack as cool & comfortable.
 Nevertheless the rise in temperature of the region under the pack averages 5˚C at the end
of treatment session – usually 15 – 20min.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 28
INDICATIONS FOR HYDROCOLLATOR PACKS
 Pain & muscle spasm
 Inflammation.
 Edema.
 Adhesions.
 As a preliminary treatment to other modalities.
GENERAL & LOCAL CONTRA-INDICATIONS FOR HYDROCOLLATOR PACKS
 Impaired Skin Sensation
 Circulatory dysfunction
 Analgesic drugs
 Infections and open wounds
 Cancer and Tuberculosis
 Gross Oedema
 Lack of Comprehension
 Deep X-Ray Therapy
 Liniment
WHEN IDEALLY TO SELECT HYDROCOLLATOR PACKS

Whenever there is a need for penetrating heat more than superficial & the patient is able to tolerate
the weight of the pack
GUIDELINES FOR THE SAFE USE OF HYDROCOLLATOR THERAPY
 Receive the patient & read the case sheet
 Question the patient regarding any contra indications & about any previous thermotherapy
treatments
 Collect the essential / appropriate materials needed for the treatment
 Check the unit, packs & power cords
 Put the patient in a well relaxed & comfortably supported position
 Position yourself near to the patient & the unit
 Prepare the specific area for the treatment
 Give adequate instruction & warning to the patient before to the start of treatment
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 29
 Place the hot pack with appropriate toweling in the treatment area. Once every 5min ask
the feedback from the patient regarding the heat perception & do the necessary changes
 Set the treatment time usually for 15 – 20 min
 Complete the treatment & check for any adverse reactions in the treatment area
 Wind-up the materials
 Document / record all the details in the case sheet including the patient response to therapy
Follow up the patient by providing him the next appointment.
PARAFFIN WAX BATH / MOIST HEAT THERAPY – SUMMARY
A paraffin bath is a simple and efficient, although somewhat messy, technique for applying a
fairly high degree of localized heat to the skin. It is an application of the molten paraffin wax on
the body part. The paraffin wax is mostly found as a white, odorless, tasteless & waxy solid.
The temperature / melting point of the wax is maintained at 55°c. If the molten wax at 55°c is
poured on the body part, it may cause burn over the body tissue, which is why some impurity is
added to lower down its melting point such as liquid paraffin or mineral oil.
The combination of the wax, paraffin and the mineral oil has low specific heat & lowers the
temperature of wax to 40 - 44̊C which enhances the patient’s ability to tolerate heat from the wax
better than from the water of the same temperature. The ratio of the wax: paraffin: mineral oil is
7:3:1 or Wax: paraffin or mineral oil is 7:1.
Why wax? – For its low specific heat capacity
Why paraffin oil? – Keep the wax liquid at lower temp & prevent burns. For its low thermal
conductivity
Why mineral oil? – It soothes and moisturizes the skin & opens pores
The mode of the transmission of heat from paraffin to the patient skin is by means of conduction.
Paraffin treatments provide six times the amount of heat available in water because the mineral oil
in the paraffin lowers the melting point of the paraffin. Paraffin provides a superficial heat, with a
depth of therapeutic heating of about 1 cm. However, because paraffin is generally used only for
the hands and feet, the depth of penetration is adequate to warm these joints to a therapeutic range.
CHARACTERISTICS OF WAX
 Low specific heat
 Low thermal conductivity - Gives of heat very slowly – no rapid loss of heat
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 30
 It is self - insulating. (The first layer creates a thin layer of air next to the skin which acts
as an insulator)
INDICATIONS
 Pain and Muscle Spasm:
 Oedema and Inflammation - The gentle heat reduces post-traumatic swelling of the hands
and feet and also swelling in hands affected by rheumatoid arthritis or degenerative joint
disease, particularly in the sub-acute and early chronic stages of inflammation.
 Adhesions and Scars - It softens the adhesion and scar in the skin and thus facilitates the
mobilization and stretching procedures.
GENERAL & LOCAL CONTRA-INDICATIONS
 Impaired skin sensation - This will be determined by a hot/cold skin test.
 Some Dermatological conditions - Are exacerbated by moist heat, such as eczema,
athlete’s foot and dermatitis. Any dermatological condition, which appears after treatment,
must be reported.
 Circulatory Dysfunction - Patients with varicose veins, deep vein thrombosis and arterial
disease must not have any heat applied directly over the affected part.
 Analgesic Drugs - If patients are taking strong narcotics for pain, the time and dosage of
the drugs must be ascertained. Heat is not administered immediately after intake of drugs,
since pain tolerance to heat is impaired.
 Infections and open wounds - Heat will increase the infective activity.
 Cancer or tuberculosis - In the area to be treated, heat, by increasing the metabolic rate,
may increase the rate of growth and spread the disease.
 Gross oedema - With a very thin and delicate skin covering the area, the skin may be
damaged and the heat may tend to increase the oedema.
 Lack of comprehension - Patients who cannot understand the nature of the treatment and
comprehend the potential danger, for example, children, very old patients, other
nationalities.
 Deep X-ray Therapy - Within three months prior to treatment decrease blood flow in the
area and may cause impaired skin sensation.
 Acute injury or Inflammation
 Recent or Potential hemorrhage
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 31
TECHNIQUES / METHODS OF APPLICATION
 Direct pouring method
 Brushing / Painting method
 Dip & Immerse / Dip & Leave in method
 Dip & Wrap / Glove method

Towelling / Bandaging method
WHEN IDEALLY TO SELECT PWB THERAPY

This is particularly effective in the hands and feet following a period of immobilization.

The majority of paraffin baths are used for chronic arthritis in the hands and feet.

If the patient has a chronic hand or foot problem, the use of paraffin instead of water
usually gives longer lasting pain relief.
GUIDELINES FOR THE SAFE USE OF PWB THERAPY
 Receive the patient & read the case sheet
 Question the patient regarding any contra indications & about any previous thermotherapy
treatments
 Collect the essential / appropriate materials needed for the treatment
 Check the unit, warmth of PWB & power cords
 Put the patient in a well relaxed & comfortably supported position
 Position yourself near to the patient & the unit
 Prepare the specific area for the treatment
 Give adequate instruction & warning to the patient before to the start of treatment
 Choose appropriate method of application to treat the area. Take proper care when treating
with oedema & appropriate positioning of the limb. Once sufficient number of coat is
formed in the area, cover it with plastic sheet & with towel to prevent the heat loss to the
environment. (Except for the method – Dip & leave in – in which the treatment area is
kept well inside the wax bath)
 The treatment time is usually for 20 – 30 min
 Complete the treatment & check for any adverse reactions in the treatment area
 Wind-up the materials
 Document / record all the details in the case sheet including the patient response to therapy
Follow up the patient by providing him the next appointment.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 32
CRYOTHERAPY – SUMMARY
Cryotherapy refers to the use of local or general body cooling for therapeutic purposes. It is the
use of cold in the treatment of acute trauma and subacute injury and for the decrease of discomfort
after reconditioning and rehabilitation. Cooling the body surface is simply the transfer of heat
energy away from the tissues. The primary methods of cooling are by conduction & convection.
It has been hypothesized that when local temperature is lowered considerably for a period of about
30 minutes, intermittent periods of vasodilation occur, lasting 4-6 minutes. Then vasoconstriction
recurs for a 15- to 30-minute cycle, followed again by vasodilation. This phenomenon is known as
the hunting response and is necessary to prevent local tissue injury caused by cold.
SENSORY PERCEPTION OF COOLING / FOUR STAGES OF CRYOTHERAPY
 Cold
 Stinging
 Burning / Aching
 Numbness
PHYSIOLOGICAL EFFECTS OF COLD
Decreased local temperature, in some cases to a considerable depth
Decreased metabolism
Vasoconstriction of arterioles and capillaries (at first)
Decreased blood flow (at first)
Decreased nerve conduction velocity
Decreased delivery of leukocytes and phagocytes
Decreased lymphatic and venous drainage
Decreased muscle excitability
Decreased muscle spindle depolarization
Decreased formation and accumulation of edema
Extreme anaesthetic effects
INDICATIONS
 During acute or subacute inflammation
 Acute & Chronic pain
 Acute swelling (controlling hemorrhage and edema)
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 33
 Myofascial trigger points
 Muscle guarding & Muscle spasm
 Acute muscle strain
 Acute ligament sprain
 Acute contusion
 Acute Bursitis
 Acute Tenosynovitis
 Acute Tendinitis
 Delayed onset muscle soreness
GENERAL & LOCAL CONTRAINDICATIONS
 Impaired circulation & sensation
 Peripheral vascular disease
 Hypersensitivity to cold - Cold urticaria, Hemoglobinuria and Cryoglobinaemia
 Vasospastic disorders - Reynaud’s Phenomena
 Skin anesthesia
 Open wounds or skin conditions
 Infection
 Cardiac diseases – Coronary artery disease
 Hypertension
 Some rheumatoid conditions
 Emotional & psychological features
METHODS OF APPLICATION OF CRYOTHERAPY
 Local immersion method (ice bath / cold bath)
 Ice packs
 Commercial cold packs
 Ice towels
 Ice massage
 Cold compression units
 Evaporating sprays
 Cryo-kinetics

Cryo-stretch

Cold whirlpool
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 34
DURATION OF CRYOTHERAPY

The length of treatment time needed to cool tissue effectively depends on differences in
subcutaneous tissue thickness.

Usually a minimum of 5 - 15 minutes is necessary to achieve extreme analgesic effects.
DEPTH OF PENETRATION OF COLD
It depends on
 The amount / type of cold
 The length of the treatment time
 Also related to intensity of cold application
 The thickness of the subcutaneous fat
 The region of the body on which it is applied
 The circulatory response to the body segment exposed.
(If deeper penetration is desired, ice therapy is most effective using ice towels, ice packs, ice
massage, and ice whirlpools.)
WHIRLPOOL / HYDROTHERAPY - SUMMARY
Treatment of different conditions of patients using the therapeutic application of water with the
help of whirlpool or Hubbard tank.
HYDROTHERAPY IS PARTICULARLY APPROPRIATE FOR TREATING:
 Neurological conditions
 Arthritis
 Low back, thoracic or neck pain
 Musculoskeletal injury
 Learning difficulties
 Post-surgery
 Cardiac Rehabilitation
GENERAL HEALTH BENEFITS OF HYDROTHERAPY
 Increase mobility
 Reduce pain and muscle spasm
 Improve and maintain joint range of movement
 Strengthen weak muscle groups
 Increase physical fitness and functional tolerances
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 35
 Re-educate normal movement patterns
 Improve balance
 Improve co-ordination
 Improve posture
 Improve self confidence
 Stimulate circulation
WHAT HAPPENS TO THE PATIENT DURING HYDROTHERAPY?
When you are in pain or under stress, chemical changes in your body can cause the blood pressure
and pulse rate to increase; Having regular hydrotherapy treatments can help you to reduce these
symptoms by relieving swollen joints and slowing down the process of stress reaction. This will
help you to relax and unwind, which is easier for you, helping you to deal with your pain.
In your first treatment
 After 5 minutes - your blood pressure and pulse rates start to drop.
 After 10 minutes - your circulation improves in your hands and feet making them warmer.
 After 15 minutes - your muscles will relax becoming more receptive to passive exercise,
fibrous tissue becomes more pliable and responsive to stretching encouraging the release
of lactic acid and other toxins from your system.
 After 20 minutes - your aches and pains will experience a temporary decrease in severity.
 Further Treatments
 After 3 treatments - your immune system will be improved.
 After 5 treatments - tension, emotional and physical pain will noticeably be reduced.
 After 10 treatments - your pain relief will be longer lasting, you'll experience a greater
sense of well-being.
 After 20 treatments - you will have a heightened tolerance to disease and depression, your
skin will be clearer and glow with health and your muscle tone and mobility will improve.
GENERAL KEY PRINCIPLES TO KNOW IN WHIRLPOOL THERAPY
 Archimedes principle
 Pascal’s law
 Buoyancy
 Laminar / streamline flow
 Turbulent flow
THERAPEUTIC EFFECTS OF EXERCISE IN WATER:
 The relief of pain & muscle spasm
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 36
 Maintenance or increase in range of motion of joints
 The strengthening of weak muscles & an increase in their tolerance to exercise
 The re-education paralyzed muscles
 The improvement of circulation
 The encouragement of functional activities
 The maintenance & improvement of balance, co-ordination & posture
 Wound healing is enhanced
 Sedative effect & relaxation
 Facilitates cardiovascular exercises
 Facilitates the weight bearing activities
INDICATIONS
 Muscle weakness
 Loss of joint mobility
 Neurological conditions
 Musculoskeletal conditions
 Sports injuries
 Wound healing
CONTRAINDICATIONS
 Skin infection – tenia pedis
 Epileptic patients / uncontrolled seizures
 Ischemic heart disease
 Patients with poor respiratory function
 Urinary incontinence
 Hydrophobic patients
 Hemophilia
 Hyperpyrexia
 Vertigo
 High / low B.P.
 Mentally retarted patients
 Severe peripheral vascular diseases
 Recent stroke attack
 Any renal diseases / severe kidney diseases
TECHNIQUES IN CURRENT USE
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 37
 Treatment schools of Thought, These include;
 Bad Ragaz ring method (BRRM)
 Halliwick method
 Watsu
SPECIALIZED DEVICES & TECHNOLOGIES USED IN WIRLPOOLBATH
1. FLOTATION DEVICES: For central trunk flotation – NEO-PRENE VESTS & FOAM WAIST-BELTS are most
commonly used. Bad Ragaz techniques use FOAM RINGS that are placed around arms &
legs or under head.
Other devices are;

Kick boards

Leg floats

Vinyl foam flexible buoys
2. RESISTIVE DEVICES: Finned dumbbells
 Finned boots
 Kick boards
 Flotation devices
BASIC TECHNIQUES USED IN WHIRLPOOL THERAPY
BALANCE TRAINING
 Balance in water is maintained by both buoyancy & hydrostatic pressure.
 Buoyancy can offer enough support to the extremities reducing the compressive forces that
would be experienced out of water.
 The hydrostatic pressure is equal in all directions & slight movement makes the body to
turning forces & the patient should be trained to return the body back to original position
without fall.
 The therapist produce turbulence on one side of the patient which cause him / her to fall &
the patient should prevent it by contracting the opposite side muscles.
STRENGTHENING
 Buoyancy can be used both as ASSIATANCE & also as a RESISTANCE. The upward
movement to the surface is ASSISTED BY THE BUOYANCY & the downward
movement away from the surface is RESISTED BY BUOYANCY.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 38
 As the hydrostatic pressure is proportional to the depth of immersion, exercise will be
easier to perform closer to the surface where pressure is less & in depth where pressure is
high the resistance to exercise is more.
Further progression in resistance can be done by;
 Increasing the length of the lever arm / weight arm
 Increasing the surface area of the part to be moved
 Increasing the turbulence
 Increasing the velocity of movement
 Adding weights to the part to be moved
 Manual resistance by the therapist.
MOBILIZATION
 Exercise in whirlpool may be of great value in increasing range of joint movement.
 The water promotes relaxation & will also relieve pain so that protective muscle spasm
may be reduced.
 Good fixation of the rest of the body should be obtained by use of support / holding on
fixed apparatus.
 Starting position should be selected to allow maximum range of movement.
 Buoyancy should be used to assist the movement / counter balance the gravity.
 Slow movements should be used to minimize the turbulence & thus resistance to the
movement.
 Using long weight arm will allow sweeping movements through water & may take the
movement beyond the point of limitation
WOUND DEBRIDEMENT
 Hydrotherapy can be utilized to debride, soften & loosen adherent devitalized tissues.
 It cleanses dirt, foreign bodies, exudate from topical agents
ANALGESIA & SEDATION
 Mechanical stimulation of skin receptors with gentle whirlpool agitation assists in
decreasing pain.
 Thermal effects also assist in pain relief by increasing circulation.
Electrotherapy Modality in a nut shell – by
Loganathan Chandrasekar, M.P.T.Sports, lecturer, Majmaah University, CAMS, KSA.
Page 39