Introductionto Ph icalA7ents

:,'i l

SUMMARY OF IIVFO RMATlOA/ COVERED

Definitions and Examplesof PhysicalAgents The Role of PhysicalAgents in Rehabilitation
Categoriesof PhysicalAgents Effectsof PhysicalAgents
History of the Use of PhysicalAgentsin Medicine GeneralContraindicationsand Precautionsfor the
and Rehabilitation Use of PhysicalAgents
The Role of Rehabilitationin Patient Care Chapter Review

t,
, ,.,.,

OB]ECTIVES
UVoncomVletion
of this chayter,thereaderwill beable to:
t . Describe, categorize, and compare the types of 5 . Identify the physiologic effects of physical
physical agents used in rehabilitation. agents.
2 . Summarize the history of the clinical 6 . Outline the general contraindications and
application of physical agents. precautions for the use of physical agents.
3 . Explain the role of rehabilitation in patient care.
4 . Explain the role of physical agents in
rehabilitation.
 'l o Introduction
This book is intended primarily as a course text for
those learning to use physical agentsin rehabilitation.
It was written both to meet the needs of studenrs
learning about the theory and practice of applying
physical agents and to assistpracricing rehabilitation
professionalsin reviewing and updating their knowl-
edge about the use of physical agents. This book
describes the effects of physrcal agents, gives
guidelines on when and how physical agents can be
most effectively and safely appiied, and describes
the outcomes that can be expected from integrating
physical agents wrthm a program of rehabilitation.
The theory underlying the application of each
agent and the researchconcerning its effects are cov-
ered to provide a rationale for the treatment recom-
mendations. Information is also provided on the
physiologlc processesnfluenced by physical agents
in general,and regardingthe specific effects produced
by specific agents.After reading this book, rhe reader
will be able to integrate the ideal physical agenr(s)and
treatment parameters within a complete program of
rehabilitation care to promore optimal patient out-
co m e.
This book uses a framework for describing the
clinical use of physical agenrs based on rhe Gwde to
PhysrcalTherapstPracilce,2ndedttion (herein nored as
the Guide).1However, this book presentsmore spe-
cific, research-basedinformation regarding the the-
aU, rationale, assessment process, and treatment
parametersfor the applicarion of physical agentsthan
provided by the Guide. It is important ro note that
the Guide is based on descriptions of preferred
practice patterns for selected patient diagnostic
groups. These practice patterns are not prescriptive,
nor are they based on a review of available research
evidence.
Following this introductory chapter, the book
rs divided into three secrions.The first section cov-
ers the different rypes of musculoskeletaland neuro-
muscuiar problems that may be addressed by the
use of physical agents. The second section describes
the physical properties, physiologic effecrs, and
application techniques for the different rypes of
physical agents available.The third secrion integrates
information from the first wvo and summarizes
how different rypes of problems may be influenced
by different physical agenrs, how rreatments with
physical agents may be integrated into a patienr's
compiete plan of care, and how physical agenrsmay
be applied under different health care delivery
to Physical Agents
systems.The final chapter discussesdirectionsfor
future researchon the useof physrcalagentsin reha-
bilitation.A glossaryof termsand abbreviationsused
in describingand documentingthe apphcationof
physicalagentsrs provrdedin Appendx A on pages
456-459.
DEFINITIONS
ANDEXAMPLES
OFPHYSICAL
AGENTS
Physicalagentsare various forms and means of apply-
ing of energy and materials to parienrs. Physical
agents include heat, cold, water, pressure, sound,
electromagnetrcradratron,and electncalcurrents.The
term Vhysicalagentcan be used to describethe general
rype of energy,such as electromagnetic radiation or
sound; a specific range within the generaltype, such
as ultraviolet radiation or ultrasound and the actual
means of applying the energy, such as an ultravioiet
lamp or an ultrasound transducer.The rerms Vhysical
modality and modality are also frequently used in
place of the term yhysical agent and are used inter-
changeably in this book, with variation for ease of
reading.
CATEGORIES
OFPHYSICAL
AGENTS
Physical agents are most readlly categorized as
thermal, mechanical,or electromagnenc (Table 1-1).
Thermal agents include deep-heatingagents,superfi-
cial heating agents, and superficial cooling agents.
Mechanical agents include traction, compresston,
water, and sound. Electromagnetic agents include
electromagneticfields and electricalcurrents.
Thermal
Agents
Thermal agents transfer energy to a patient to pro-
duce an increase or decreasein tissue temperature.
Different thermal agents produce the greatestchange
in temperature in different rypes and areas of tissue.
For example, a hot pack producesthe greatesttemper-
ature increasein superficial tissueswith hrgh thermal
conductiviry in the area directly below rt. In contrast,
an ultrasound produces the most heat in tissues
with high ultrasound absorption coefficlents, such
as tendon and bone. It produces this effect up to
a depth of 5 cm but only in a small area, approxi-
mately twice that of the effective radiating area of the
transducer.
 4 o INTRODUCTION TO PHYSICAL ACENTS
Thermal Deep-heatmg agents
Superficral heatrng agents
Cooling agents
Mechanical Tracuon
Compressron
Water
Sound
Electromagnertc Electromagnetlc fields
Electrrc currents
Thermal agents that increase tissue temperature
are most commonly appliedwhen increasing of circu-
lation, metabolic rate, and soft tissue extensibiliry or
the decrease of pain ire expected to promote the
goals of treatment. Thermal agents that decreasetis-
sue temperature are most commonly applied when
decreasing circulation, metabolic rate, or pain is
expected to promote the treatment goals. A full dis-
cussion of the principles underlying the processesof
heat transfer, the methods of heat transfer used in
rehabilitation, and the effects, indications, and con-
traindications for applying superficial heating and
cooling agents is provided in Chapter 6. The princi-
ples and practice of applying deep heating agents are
discussedin ChapterT inthe section on thermal appli-
carions of ultrasound and in Chapter 1,2inthe section
on diathermy.
Ultrasound is a form of sound that cannot be heard
by humans becauseof its high frequency. It is defined
as sound with a frequency of greater than 20,000
qgcles/second. Ultrasound a mechanical form of
enerry composed of alternatingwaves of compression
a.rrdrarefaction. Ultrasound is used as a physical agent
:n rehabilitation to produce both thermal and nonther-
nal effects. Thermal effects, including increased deep
and superficial tissue temperature, are produced by
:ontinuous ultrasound waves of a sufficient intensiry
while nonthermal mechanical effects, including cavi-
adon, microstreaming, and acoustic streaming, are
?roduced by both continuous and pulsed ultrasound.
l-hermal-level ultrasound is used for the same pur-
:oses as other thermal agents when deep tissue is
rvolved. These purposes include increasing circula-
Drathermy
Hot pack
Ice pack
Mechamcal tracuon
Elastrcbandage
Whrrlpool
Ultrasound
Ultravrolet
TENS
tion, metabohc rate, and soft tissue extensibiliry and
decreasing pain. Ultrasound is applied in a pulsed
manner to optlmlze the nonthermal effects and facili-
tate tissue healing or promote transdermal drug pene-
tration. Further information on the theory and practice
of applying ultrasound can be found in Chapter 7.
Agents
Mechanical
Mechamcal agents apply mechanical force to
increaseor decreasepressurein or on the body. Water
provides resistanceto increaselocal pressure,hydro-
static pressure to increase circumferential pressure,
and buoyancy to decreasepressureon weight-bearing
structures. Traction decreasesthe pressure berween
structures, and compression increases the Pressure
between structures.
Water can be applied by immersion or nonimmer-
sion techmques.The therapeutic application of water
is known as hydrotherafy. Immersion in water pro-
duces pressure around the immersed area, provides
buoyancy, and, if there rs a difference in temperature
between the area and the water, transfers heat to or
from the area.Movement of the water produces local
pressure,which can be used as resistancefor exercise
when an areais immersed and for cieansingor debrid-
ing openwounds with orwithout immersion. Further
information on the theory and practice of hydrother-
apy is provided in Chapter 9.
Tracilon is most commonly used to alleviate pres-
sure on structures, such as nerves or joints that pro-
duce pain or other sensory changes or that become
inflamed when compressed.Tractron application can
 4 c Introduction
normalize sensationand prevent or reduce damage or
inflammation of compressed structures. The pres-
sure-relievingeffects of traction may be temporcry or
permanent, depending on the nature of the underly-
ing pathology and the force, duration, and means of
traction application used. Further information on the
theory and practice of applying traction is provided in
Chapter 10.
Compression is used to counteract tluid pressure
and control or reverse edema. The force, duration,
and means of application of compression can be var-
ied to control the magnitude of the effect and to
accommodate different patient needs. Further infor-
mation on the theory and practice of applying com-
pressionis provided in Chapter 1,1,.
neticAgents
Electromag
Electromagneti c agents apply electro magnetrc energy
in the form of electromagneticradiation or an electri-
cal current. Variation of the frequency and intensity of
electromagnetic radiation changes its effects and
depth of penetration. For example, ultraviolet radia-
tion, which has a frequency of 7.5 x 1914so 1915
cycles/second,produces erythema and tanning of the
skin but does not produce heat, whereas infrared radi-
ation, which has a frequency of 1011 to L014
cycles/second,produces heat only in superficial tis-
sues. Continuous shorrwave diathertrtl, which has a
frequency of 10 million to 100 million cycles/second,
produces heat in both superficial and deep tissues.
When shortwave diathermy is pulsed to provide a
low average intensity of energy,it does not produce
heat; however, the electromagneticenergy is thought
to modify cell membrane permeabiliry and cell func-
tion by nonthermal mechanisms and thus acts to con-
trol pain and edema. Further information on the
theory and practice of applying electromagnetic radi-
ation is provided in Chapter 12.
The effects and clinical applications of electrical
currents vary according to the waveform, intensiry
duration, and direction of the current flow and
according to the rype of tissue to which the current is
applied. Electrical currents of sufficient intensiry and
duration can depolarize nerves, causing sensory or
motor responsesthat may be used to control pain or
increase muscle strength and control. Electrical cur-
rents with an appropriate direction of flow can attract
or repel chargedparticlesand alter cell membrane per-
meabiliry to control the formation of edema, promote
to Physical Agents
tissue healing, and facilitate transdermal drug pene-
tration. Further information on the theory and prac-
tice of electrical current application is provided in
Chapter B.
AGENTS
OFTHEUSEOFPHYSICAL
HISTORY
ANDREHABILITATION
INMEDICINE
Physical agents have been a component of medical
and rehabilitation treatment for many centuries and
are used acrossa wide variery of cultures. For exam-
ple, the remains of origrnal bath houses with steam
rooms and pools of hot and cold water that can still be
seen in many major cities of the ancient Romans and
Greeks provide evidencethat these cultures used heat
and water to maintain health and treat various mus-
culoskeletal and respiratory problems.2 The health
benefits of soaking and exercising in hot water
regained populariry many centuries later with the
advent of health spas in Europe in the late 19th cen-
tury in areas of natural hot springs. Today, the pracr
tices of soaking and exercising in water continue to be
popular throughout the world becausethey provide
resistance, thereby allowing the development of
strength, endurance, and buoyancy, and reducing
weight bearing on compression-sensitivej oints.
Other examples of the historic use of physical
agents include the use of torpedo fish, in approxr-
mately 400 n.c., to apply electric shocks to the head
and feet to treat headachesand arthritis, and the use
of amber in the 17th century to generate static elec-
triciry for the treatment of skin diseases,inflamma-
tion, and hemorrhage.3 There are also reports from
rhe LTth century of charged gold leaf being used to
prevent scarringfrom smallpox lesions.a
Before the widespread availabiliry of antibiotics
and effective analgesic and antiinflammatory drugs,
physical agents were commonly used to treat infec-
tion, pain, and inflammation. Examples of such appli-
cations include the use of sunlight for the treatment of
tuberculosis, bone and joint diseases,and dermato-
logic disorders and infections, and the use of warm
Epsom salt baths for the treatment of sore or swollen
limbs.
Although physical agentshave been used for their
therapeutic benefits throughout history over time,
new uses, applications, and agents have been devel-
oped, and certain other agents and applications have
fallen out of favor. New uses of physical agents have
developed as a result of increased understanding of
 I o INTRODUCTION TO PHYSICAL AGENTS
the biologic processesunderlying disease, dysfunc-
tion, and recovery, and in response to the availability
of advancedtechnology. For example, the use of tran-
scutaneous electrical nerve stimulation (TENS) for the
treatment of pain was developed based on the gate
control theory of pain modulation, as proposed by
Melzack and Wall. In contrast, the various modes of
TENS application now available are primarily the
result of the recent development of electrical current
generators that allow fine control of the frequency,
intensiry, and pulse duration of the applied electrical
current.
The use or specific application of a physical agent
falling out of favor, usually occurs because the treat-
ment is ineffective or because other, more effective
ffeatments are developed. For example, infrared lamps
were commonly used to treat open wounds because
the superficialheat they provide can dry out the wound
bed; however, these lamps are no longer used for this
appiication because of the knowledge that wounds
heal more rapidly when kept moist.5,6 During the
early years of the 20th century sunlight was used to
treat tuberculosis; however, since the advent of
antibiotics, which are generally effective in eliminat-
nng bacterial infections, physical agents are now
rarely used to treat tuberculosis or other infectious
diseases.A number of physical agentshave waned in
populariry becausethey are cumbersome,have exces-
sive associatedrisks, or interfere with other aspectsof
ffeatment. For example, the use of diathermy as a
Ceep-heatingagent was very popular 20 to 30 years
ago, but becausethe machines are large and awkward
:o move around, can easily burn patients if not used
appropriately, and the electromagnetic fields can
nterfere with the functioning of computer-controlled
equipmentnearby, diathermy is rarely currently used
-l the United States.
This book focuses on the physical agents most
:ommonly used in the United States today. Physical
sgents that are not commonly of current use in the
',-nited
Statesbut were popular in the recent past, and
iose that are popular abroad or are expectedto come
back into favor as new delivery systems and applica-
:ons are developed, are covered more briefly. Also
-:rcludedin this book is some discussionof modalities
:urently being used abroad that are awaiting
:nproval by the Food and Drug Administration (FDA)
:er clinical use in the United States.The populariry of
:arricular physical agentsand applications is basedon
:eir history of clinical use and, in most cases,
research data supporting their efftcacy; however, in
some cases,their clinical application has continued
despite the lack or limitations of supporting evidence.
In most cases,more researchis necessaryto elucidate
the ideal treatment and patient characteristics for
optimal resultsand the precisenature of the outcomes
to be expectedfrom the application of physical agents
in rehabilitation.
THEROLEOFREHABILITATION
INPATIENT
CARE
Rehabilitation is a goal-oriented treatment process
designed to maximize independence in individuals
who have compromised function as a result of
underlying pathologic processes and secondary
impairments. Rehabilitation generally addressesthe
sequelae of pathology rather than the pathology
itself.
A number of classification schemes exist to
categorrze the sequelae of pathology. In 1980 the
Wodd Health Orgaruzation (\MHO) published the
first classification scheme known as the International
Classification of Impairments, Disabilities and
Handicaps (ICIDH).7-eThir scheme, based primarily
on the work of Wood, classifies the sequelae of
pathology as impairments, disabilities, and handi-
caps.10,11 Shordy thereafter, Nagi developed a model
that classified the sequelae of pathology as impair-
ments, functional limitations, and disabilities.12In
L993, the National Center for Medical Rehabilitation
Research(NCMRR) published a classificationscheme
der:ed from a combination of the Nagi model and
the original ICIDH mode1.13Most recently, in2001,
WHO further revised their classification scheme in
their International Classification of Functioning,
Disabiliry and Health (ICIDH-2) scheme.la
The models of disability and the language used
have been revised over time to reflect and creare
changesin perceptions of people with disabilities and
to meet the needs of different groups of individuals.
The original models were intended to differentiate
disease and pathology from the limitations they
produced. These models were developed primarily
for use by rehabilitation professionals. The new
expandedmodels have a more positive perspectiveon
the changes resulting from pathology and diseaseand
are intended for use by a wide range of people, includ-
ing communiry, national, and global institutions that
create policy and allocate resourcesfor persons with
5 4 o Introduction
disabilities. Specifically,the NCMRR model added a
category of societallimitations to the functional prob-
lems associatedwith disabiliry and it abandoned the
previous linear modeling approach to reflect the fre-
quently nonsequential nature of the relationships
bewveen categories.The ICIDH-2 has tried to change
the perspective of disabiliry from the negative focus
of "consequencesof disease"used in the 1980 model
to a more positive focus on "components of health."
Thus, while the first ICIDH used categoriesof impair-
ments, disabilities, and handicaps to describe seque-
lae of pathology, ICIDH-2 uses categories of health
conditions, body functions, activities, and participa-
tion to focus on abilities rather than on restrictions
and limitations.
This book usesa scheme consistentwith the termi-
nology and framework of the Cuide to Physical
TherapistPractice,2nd edition, which is based on the
work of Nagi (Fig. 1-1), to evaluate clinical findings
and determine a plan of care for the casestudies pre-
sented.l
Pathology
Diseaseor injury
Functional limitation
Restrictionsin the ability
to performcomponents
of daily life
Disability
Inabilityto performtypical
activitiesof daily living
Figure1-1, Ciassificationof the sequelaeof pathology.
(Data from American Physicai Therapy Association:
Cuide to PhysicalTheraqstPractice,ed 2, Alexandria,VA,
200I, The Associatron.)
to Physical Agents
According to the Nagi scheme, the sequelae of
pathology are classified as impairments, functional
limitations, or disabilities.T,r2Pathologyrefers to the
alteration of anatomy or physiology due to diseaseor
injury. Lumbar disc herniation and joint inflammation
are examples of pathology.
Impairments are defined as alterations in
anatomic, physiologic, or psychologic structures or
functions as the result of some underlying pathol-
agy.7'rzAn impairment is a measure at the organ or
organ system level and is equivalent to a sign or an
objective measure. For exampie, decreased cervic
mobiliry diminished deep tendon reflexes, and
absent sensation are all impairments. Impairments
may lead to functional limitations or disabilities.
A functional limitation, as defined by the Nagi
model, is a restriction in the abiliry to perform an
acdviry in an efficient, typically expected, or com-
petent manner. Examples of this classification
include an inabiliry to lift more than 20lbs or a limita-
tion in sitting tolerance. The Nagi model, then,
defines a disabiliry as the inabiliry to perform activi-
ties requiredfor self-care,home, work, or community
roles. Examples of disabiliry according to the Nagi
model are the inabiliry to lift one's child or to walk to
the bathroom at home.
While medical treatment is genenlly'directed at
the underlying pathology or disease, rehabilitation
focuses primarily on reversing or minimizing the
associated impairments, functional limitations, and
disabilities. Essentially, rehabilitation professionals
must assessand set goals not only at the level of
impairment, such as pain, decreasedrange of motion,
or hypertonicity, but also at the level of functional
limitation. These goals should include the patient's
goals, such as being abie to get out of bed, ride a bicy-
cle, work, or compete in a marathon.
THEROLE
OFPHYSICAL
AGENTS
INREHABILITATION
Physical agents are tools to be used, when appropri-
ate, as components of rehabiiitation. The American
Physical Therapy Association's (APTA) position state-
ment concerning the exclusive use of physical agents,
published in 1995, states that "Without documenta-
tion which justifies the necessiryof the exclusive use
of physical agents/modalities, the use of physical
agents/modalities, in the absenceof other skilled ther-
apeutic or educational intervention, should not be
 ,I o INTRODUCTION TO PHYSICAL AGENTS
considered physical therapy.'1s This is a clear state-
ment that the APTA believes that the use of physical
agents alone does not generally constitute physical
therapy, and that, in most cases, physical agents
should be applied in conjuncrion with orher inrerven-
tions. The skilled application of physical agents that
constitutes a component of physic altherapy involves
the integration of the appropriate intervention(s),
which may include the application of a physical agent
or agentsor the education of the patienr in such appli-
cation, into the complete program of a patient,s care
to facilitate progress toward the functional goals of
ffeatment.
The aim of this text is to give clinicians a berter
understanding of the theory and appropriate applica-
:ion of physical agents.Therefore the examples, doc-
umentation, and clinical casestudies described focus
rn the physrcal agent being discussed.Inclusion of all
eossible goals and interventions for a given impair-
:rrent or iimitation is beyond the scope of this book.
Physical agents have direct effects primarily at the
-evel of impairment. These effects can then promote
-:nprovements at the levels of functional limitation
disability. Physical agents are used primarily to
"nd
:educe or eliminate soft tissue inflammation or circu-
-atory dysfunction, increase the healing rate for soft
::ssue in1ury, modulate pain, modify tone, increase
:onnective tissue extensibiliry and length, remodel
--:artissue,or treat skin conditions. For example, ther-
=al agents can be used to increase circulation and
,:celerate the metabolic rate to acceieratehealing,
:::d electrical currents can be used to stimulate sen-
:1ry nerves to control pain or to stimulate motor
:-irves to produce muscle contractions.
Physical agents are frequently used in conjunction
',-:fi, or in preparation for, other interventions such as
--:-erapeuticexercise, functional
training, or manual
:-cbrhzation to increase the efficacy of these inter-
=rtions. For example, a hot pack may be applied
:=:ore stretching to increase the extensibiliry of the
:::erficial soft tissuesand thus promote a more effec-
:'.'e and safe increase in soft tissue length when the
,:etching force is applied.
r,Vhen considering rhe application
of a physical
.:ent, one should begin the examination by checking
: -r physician's referral, if one is required, for a diag-
--:;is of the patient's condition and
any precautionsto
:. observed.The examination should include but nor
:= jmited to the patient's medical history; subjective
: : rplaints; review of systems, tests and meisures;
functional status; and disabilities. The examination
findings are then evaluated and, when possible,
quantified. Following this analysis, a plan of care is
established including anticipated goals. Given an
understanding of the effects of different physical
agents, the clinician can assesswhether treatment
using a physical agent may help the patient progress
toward the anticipated goals. The clinician can then
determine the treatment plan, including the ideal
physical agent(s) and treatment parameters if
indicated. The treatment plan is modified, as appro-
priate, when the patient's outcome is assessed.The
sequence of examination, evaluation, and interven-
tion is followed in the casesrudiesin Section 2 of this
book. Goals and interventions in this text prim afiIy
refer to treatment of impairment with the physical
agent(s)being discussed.
EFFECTS
OFPHYSICAL
AGENTS
Modiff inflammation and healing
Relieve pain
Alter collagen extensibility
Modiff muscle tone
The application of physical agents primarily resulrs
in modification of tissue inflammation and healing,
relief of pain, alteration of collagen extensibiliry
or modification of muscle tone. A brief review of
these processesfollows; more complete discussions
of these processes are provided in Chapters 2
through 5.
Inflammation
andHealing
When tissue is damagedby trauma or disease,it usu-
ally responds in a similar and predictable way. The
first phase of recovery after damage has occurred is
inflammation. This is followed by the proliferative
phase of healing, which is completed during rhe mat-
uration phase. Modification of inflammation and tis-
sue healing can result in acceleratedpatient progress
toward more active participation in rehabilitation and
can expedite achievement of the therapy goals. Faster
tissue repair can also reduce the risk and severiry of
the adverse effects of prolonged inflammation, pain,
and disuse.
Thermal agents generally modify inflammation
and healing by changing the rate of circulation and the
 4 o Introduction
rate of chemical reactions. Mechanical agents control
motion and alter fluid flo*, and electromagnetic
agents alter cell function, particularly membrane per-
meability and transport. When selected and applied
appropriately, physical agents can acceleratethe com-
pletion and resolution of the phasesof tissue healing,
stimulate necessaryprocessesto resume if they have
stopped, accelerate recoveryj and improve the final
patient outcome. Physical agents can also minimize
the risk of adverse effects from delayed or incomplete
healing. However, if selected or applied inappropri-
ately, physical agents may prolong inflammarion,
increasethe severity ofassociatedsymptoms, prevent
or delay healing, and increase the probabiliry of
adverse consequencesand a poor outcome. A brief
review of the processesof inflammation and healing
and the factors that influence rheir progression fol-
lows; a more complete discussion of these processes
is provided in Chapter2.
During the inflammatory phase of healing, which
generally lasts for I to 6 days, the ceils necessary for
removing debris and limiting bleeding enrer the rrau-
matized area. This phase is characterized by heat,
swelling, pain, redness, and loss of function. The
more quickly this phase is completed and resolved,
the more quickly healing can proceed and the lower
the probabiliry of joint destruction, excessive pain,
swelling, weakness, immobilization, and loss of func-
tion. Physical agents generally assist during the
inflammatory phase by reducing circulation, reducing
pain, reducing enzyme activiry rate, controlling
motion, and promoting progression to the prolifera-
tive phase of healing.
During the proliferative phase, which generally
starts within the first 3 days after injury and lasts
for approximately 20 days, collagen is deposited in
the dama ged areato replace tissue that was destroyed
by the trauma; in addition, if necessary myofibrob-
lasts contract to accelerate closure, and epithelial
cells migrate to resurface the wound. Physical agents
generally assist during the proliferative phase of
healing by increasing circulation, increasing errzyme
acdviry rate, promoting coliagen deposition, and pro-
moting progression to the remodeling phase of
healing.
During the maturation phase, which usually srarrs
approximately 9 days after the initial injury and can
last for up to 2 years, both deposition and resorption
of collagen occur. The new tissue remodels itself to
resemble the original tissue as closely as possible to
to Physical Agents
best serve its original function. During this phase, the
healing tissue changes both in shape and structure to
allow for optimal functional recovery.The shape con-
forms more closely to the original tissue, often
decreasingin size from the proliferative phase, and
the structure becomes more organized; thus, greater
strength is achieved with no change in tissue mass.
Physical agents generally assist during the remodeling
phase of healing by altering the balance of collagen
deposition and resorption and improving the align-
ment of the new collagen fibers.
PainControl
Pain is an unpleasant sensory and emotionai experi-
ence associatedwith or describedin terms of actual or
potential tissue damage.16-18puitr usually protects
individuals by preventing them from performing
activities that would cause tissue damage; however,
it may also interfere with normal activities and thus
result in functional limitation and disability. For
example, pain frequently interferes with an individ-
ual's ability to sleep,work, or exercise.Relieving pain
can allow patients to participate more fuliy in normal
activities of daily living and may acceleratethe initia-
tion of an active rehabilitation program, thereby lim-
iting the adverseconsequencesof disuseand ailowing
more rapid progress toward the patient's functional
goals.
Pain may be due to an underlying pathology, such
as joint inflammation or pressure on a nerve that is in
the processof resolution, or by a pathology, such as a
malignancy, that is not expected to fully resolve. In
either circumstance,relieving pain may facilitate reso-
lution of the functional limitations and disabiliry that
result from the underlying pathology and can there-
fore assist the patient. The use of pain-relieving
interventions, including physical agents, may be con-
tinued as long as pain persists and should be discon-
tinued when the pain resolves.
Physical agents can control pain by modi Aing
pain transmission or perception or by changing the
underlying process causing the sensation. Physical
agents may act by modulating transmission at the
spinal cord level, changing the rate of nerve conduc-
tion, or altering the central or peripheral release of
neurotransmitters. Physical agents can change the
processesthat causepain by modifying tissue inflam-
mation and healing, altering coliagen extensibility, or
modifying muscle tone. The processesof pain per-
 4 o INTRODUCTION TO PHYSICAL AGENTS
;eption and pain control are explained in greater
Cetailin Chapter 3.
Extensibility
Collagen
Collagen is the main supportive protein of skin, ten-
Con, bone cartlTage,and connective tissue.19Tissues
-hat contain collagen can become shortened as a
:esult of being immobilized in a shortened position or
-ceing
moved only through a limited range of motion.
:-mmobilization may be the result of disuse as a result
rf debilitation or peripheral or central neural injury, or
:nay be due to the application of an external device
such as a cast, brace, or external fixator. Movement
nay be limited by internai derangement, pain, weak-
:tess,or poor posture or may be due to the application
rf an external device. Soft tissue shortening may
;ause impairment of restricted joint range of motion,
shortened muscles,tendons, or joint capsules.
To return soft tissue to its normal functional
-ength, thereby allowing fuli rnotion without damag-
ng other structures, the collagen must be stretched.
Coliagen can be stretched most effectively and safely
'vhen it is most extensible. Since the extensibiliw oF
;ollagen is temperature dependent, increasing in
:esponse to increased temperature, thermal agents
are frequently applied before soft tissue stretching to
cptimize the stretching process20-24(Frg. I-2). The
processesunderlying the development and treatment
cf motion restrictions are discussed in detail in
Chapter 5.
f Physical agents can alter muscle tone either
o directly, by altering nerve conduction or sensitivity or
?h
z by altering the biomechanical properties of muscle, or
UJ
F
x indirecdy, by reducing pain or the underlying prob-
UJ
z lem causing pain. Normalizing muscle tone will
ul
(5
J
J
o
()
TEMPERATURE
Figure1-2. Changesin collagenextensibiliqyin response
ro changesin temperature.
9
Muscle
Tone
Muscle tone is the underlying tension that servesas a
background for contraction in a muscle.2s Muscle
tone is affected by both neural and biomechanical [ac-
tors and can vary in responseto a pathology, expected
demand, pain, and position.26Abnormal muscle tone
is usually the direct result of nerve pathology or is a
secondary sequela of pain due to injury of other tis-
sues."'
Central neryous system injury, as may occur
with head trauma or a stroke, can result in increased
or decreased skeletal muscle tone in the affected
area, whereas peripheral motor nerve injury as may
occur with nerve compression,traction, or sectioning,
can decrease skeletal muscle tone in the aFFected
area. For example, a patient who has had a stroke
may have increased tone in the flexor muscles of
the upper extremiry and the extensor muscies of the
lower extremity on the same side, whereas a patient
who has had a compression injury to the radial
nerve as it passesthrough the radial groove in the arm
may have decreased tone in the wrist and finger
extensors.
Pain may cause an increase or decreasein muscle
tone. Muscle tone may be increased in the muscles
surrounding a painful injured area in order to splint
the area and limit motion, or tone in a painFul area
may be decreasedas a result of inhibition. Although
protective splinting may prevent further injury as a
result of excessive activiry, if prolonged it can also
impair circulation, retarding or preventing healing.
Decreasedmuscle tone as a result of pain-as occursr
for example, with the reflexive hypotonicity of the
knee extensors-that causes buckling of the knee,
when knee extension is painful, can limit activity and
thus result in functional iimitation.
generally reduce Functionallimitations and disabiliry
allowing the individuai to improve the performance
of functional and therapeutic activities. Attempting to
normalize muscle tone may also promote better out-
comes from passive treatment techniques such as
passive mobilization or positioning. The processes
underlying changesin muscle tone are discussedfully
in Chapter 4.
10 4 e Introduction to Physical Agents

CONTRAINDICATIONS
GENERAL tion to such tissue.Somephysicalagentsaccelerate
FORTHEUSE
ANDPRECAUTIONS the growth or metastasisoFmalignanttissue.These
effectsarethoughtto resultfrom increasedcirculation
AGENTS
OFPHYSICAL or alteredcellularfunction. Care must also be taken
when consideringtreatingany areaof the body that
Pregnanry currendy has or previously had cancercelis, since
Malignanry
malignanttissuecan metastasizeand may therefore
Pacemaker
be oresentin areaswhere it hasnot yet beendetected.
Impaired sensation
Impaired mentation ih" ,rr" of physicalagentsis generallycontraindi-
catedwhen rfreenergyof the agentcanreacha pace-
makerbecausethe energyproducedby someof these
agentsmay alter the functioning of the pacemaker
Restrictionson the use of particulartreatmentinter- and thus dangerousiychangethe patient'sheartrate.
ventions are categorizedas contraindications or fre- Impairedsensationand mentationare contraindi-
cautions.Contraindicationsare conditionsthat render cationsor precautionsfor the use of many physical
a particularform of treatmentimproper or undesir- agentsbecausethe end limit for the applicationof
able,while precautionsare conditionsunder which theseagentsis the patienl'sreport of how the treat-
a particular form of treatment should be applied ment feels. For example,for most thermal agents,
with specialcareor limitations.6The terms absolute the patient'sreport of the sensationof heat being
contraindicationsand relativecontraindications can be comfortableor painful is used as a guide to limit
used in place of contraindicationsand precautions, the intensity oFthe treatment.If the patient cannot
respectively. feelheat or pain due to impairedsensation,or cannot
Although the specificcontraindicationsand pre- report this sensationaccurateiyand consistentlydue
cautions for the application of particular physical to impaired mentation or other factors affecting
agentsvary,a numberof conditionsare contraindica- the ability to communicate,the applicationof the
tions or precautionsfor the use of most physical treatmentwould not be safe and is thereforecon-
agents.Thereforecautionshouldbe usedwhen con- traindicated.
sideringapplicationof a physicalagentto a patient Specificcontraindications and precautions,includ-
with any of theseconditions.In patientswith such ing questions to ask the patient and featuresto assess
conditions,the nature of the reslriction,the nalure before before the application of eachphysicalagent,
and distribution of the physiologic eFfectsof the are provided in Section 2 of this book in eachoFthe
physicalagent,and the distributionof the energypro- chapters concerning the different types of physical
ducedby the physicalagentmust be considered. The agents.
conditionsfor which treatmentwith most physical
agentsarecontraindicated or requirecautionarc prcg CHAPTER REVIEW
nancy, malignancy,the presenceof a pacemaker,
impairedsensation,and impairedmentation. Physicalagentsarevariousforms of energyandmate-
Pregnancyis generallya contraindicationor pre- rials and their means of applicationas applied to
caution for the application of a physical agent if patients.Physicalagentsinclude heat, cold, water,
the energy produced by the agent or the physio- pressure,sound,electromagnetic radiation,and elec-
logic effectsof the agentmay reach the fetus. These trical currents. These agents can be categorizedas
restrictionsapply becausethe influences of these thermal, mechanical, or electromagnetic' Physical
types of energyon fetal development are usually agents have been used for many centuries and by
not known and because Fetai development is many cultures and continue to be used today as a
adversely affected by many influences,some oF comoonent of rehabilitation.
which aresubtle. Rehabilitationfocuseson the treatment oF the
Malignancyis a contraj.ndication or precaution for sequelae of pathology,includingimpairments,func-
the applicationof physical agents if the energy pro- tional limitations, and disabilities.Physicalagentsare
ducedby the agentor the physiologic effects oF the included in rehabilitation careprimarily to afFectthe
agentmay reach malignant tissue or alter the circuia- impairments dftecrly, thereby reducing functional
 4 I INTRODUCTION TO PHYSICAL AGENTS
limitation and disability. The use oFphysical agents is
generally integrated into a program of patient treat-
ment that includes other interventions to optimize
the benefit and outcome.
When appropriately selectedand applied, physical
agents can promote the resolution of inflammation,
acceleratetissue healing, relievepain, increasesoft tis-
sue extensi.bllity, and/or modify muscle tone. Most
physical agents should not be applied when the
energy provided by the agent or the physiologic
effects produced can reach a fetus, malignant tissue,
or a pacemaker. In addition, physical agents that use
the patient's report as a guide for dosage or intensity
should not be applied to patients with impaired sen-
sation or mentation.
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