ELECTRO 1 AY 18-19

DEEP HEATING
MODALITIES
ULTRASOUND
DIATHERMY IRR

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT Department

 P R IN C
I P LE S
• Stefan-Boltzman Law
• Kirchoff’s Law

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 TH E R A P E U T I C
U LT R A S O U N D
• High-Frequency mechanical waves delivered
using acoustic energy.
• Deep penetrating that produces changes
in tissue through thermal and nonthermal
(mechanical) mechanisms.
• Ranges from 750 , 00 0- 3, 3 00 ,00 0 Hz (0.75-
3 MHz)
• *Human ear detects sound waves fro m 16,000-
2 0 , 0 0 0 Hz.
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
 U LT R A S O U N d :
MECHANISM
• Vibrating molecules into adjacent molecules.
• Requires a physical medium such as air
• In substances (or tissues) with higher molecular
densities, transmission of US would be more
efficient because there are more molecules per
given volume

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 B I O P H YS I C A L P R O P E R TI
E SO F U LT R A S O
Ureach
• When acoustic waves N D aWpoint
AV E ofS a change
in tissue density, the waves can be reflected,
refracted, or absorbed.
• *Standing waves

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 K e y - po
in t
• More dense connective tissues, such as
ligaments and tendons, absorb US better than
less dense tissues such as muscle and fat.
Thus, US is more effective at heating more
dense tissues than less dense tissues.

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
HOW ARE U LT R A S O U
N D WAV E S PRODUCE
D?
 PA R T S O F ANU
LT R A S O U N D MAC
1.Generator – the “Big
box” H I N E
2. Applicator
• Sound head – usually
Aluminum, Stainless steel
or Ceramic
• Piezoelectric Crystal
(Lead Zirconate or
Titanate Ceramic)
• Reverse piezoelectric
effect
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
PA R T S O F ANU
LT R A S O U N D MAC
HINE

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 REV ERSE P IE Z
O E LE C T R I C E FF
• Effective Radiating Area (ERA)
E CofTthe crystal that moves is the effective
• the area
radiating area (ERA).
• ERA is smaller than the actual size of the head
• the crystal is not perfectly uniform in shape, nor does
it expand and contract uniformly across its surface
-> BEAM NON-UNIFORMITY RATIO

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
C H A R A C TE R I S TI C S
O F U LT R A S O U N D
WAV E S A N D PAR A M
 FREQ
UENC
Y 3 MHz 1 MHz
Effective Treatment 2.5 cm Depth 6 cm Depth
Depth
Rate of Absorption 3x faster than 1 MHz 3x slower than 3 MHz
Rate of Heating 3x faster than 1 MHz 3x slower than 3 MHz
Structures Exposed tendons Muscles and Fascia
and ligaments

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 I N TE N
S I TY
• Measured in watts but most
commonly watts /cm 2 (Spatial
Average Intensity)
• Formula:
• Power (watts) / ERA (cm 2 )
• No definitive standard bu t commonly used
intensity: 1.5 watts/cm 2 .

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 MO
DE
1.Continuous - US is delivered at a constant
energy level throughout the treatment
2.Pulsed - periodic cessation of the energy flow,
so no US is delivered for a period of time
• Pulse duration – time that energy is flowing
• Pulse period – combined energy flo w + lack of f low
• Duty cycle – degree t o which total energy is reduced
upon

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 BEAM NO
N U N I F
• Nonuniformity of the
O R M I T Y R A
acousticTenergy
I O at
different parts of the
collimated beam.
• ratio between the spatial
peak intensity (ISP)
measured anywhere within
the ERA and the spatial
average intensity (ISA)
averaged over the entire
ERA
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
 TR E A T M E
NT AR
• Evidence suggests that t o get significant heating
E be
effect, US must A applied in an area preferably
2x the ERA (and no greater than 4x).

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 D U R A TI O N O F T
R E A TM E N T
• Many rehabilitation professionals limit their
US treatments t o 5 t o 10 minutes, and many
insurance companies limit treatments t o 8
minutes.
• However, using 1-MHz US (1.5 watts/cm2, 2 ×
ERA), it takes 11 minutes t o heat skeletal
muscle t o 6°F (3.5°C) and even longer t o heat
t o vigorous heating of 7°F (4°C).

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 A P P LI C A TI O
N MED
• The radiating waves of US must be kept
I Ut oMthe skin surface; thus, the
perpendicular
applicator must remain in contact with the skin
surface.
• A coupling medium must be used between the
US applicator and the skin.
• The applicator faceplate must be
continually moved during the treatment.

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 A P P LI C A TI O
N MED
• The radiating waves of US must be kept
I Ut oMthe skin surface; thus, the
perpendicular
applicator must remain in contact with the skin
surface.
• A coupling medium must be used between the
US applicator and the skin.
• The applicator faceplate must be
continually moved during the treatment.

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 A P P LI C A TI O
N
• Viscous Aqueous gel
M E D
I U Mglycerin, phenoxyethanol, and
• propylene glycol,
a colorant
• Water Immersion
• over irregular surfaces
• or if the area t o be sonicated is smaller than the
faceplate of the US applicator
• US head should be within 1 cm o f the area
being sonicated
• Gel Pads
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
 VE LO C I T Y O F U LT
RASOUND MOVE
• a slow movement velocity of about 3 t o 4 cm/s.
M E N T
•Common practice – 2 / 3 seconds / revolution

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 PA TT E R N S O FM O VI N
G T
• The most common
H E S O U N DH E
A D is
pattern
overlapping circles
• Parallel strokes
either horizontally
or vertically -
overlapping the
previous stroke b y
approximately
half the ERA of
the sound head
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
 VE LO C I T Y O F U LT
RASOUND MOVE
• a slow movement velocity of about 3 t o 4 cm/s.
M E N T
•Common practice – 2 / 3 seconds / revolution

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
E FF E C T S O F U
LT R A S O U N D
 E FF E C T S O F U
LT R A S O U N D
• Thermal Effects
• Non-thermal Effects
• Cavitation
• Formation of gas bubbles

• Acoustic Streaming
• Forward movement of fluid b y US Waves
• changes in cellular permeability and the release of
substances such as histamine and other vasoactive agents

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
 E FF E C T S O F U
LT R A S O U N D
• Thermal Effects
• Deeper and affects a small area

• Non-thermal Effects
• Cavitation
• Formation of gas bubbles

• Acoustic Streaming
• Forward movement o f fluid b y US Waves
• changes in cellular permeability and the release of substances
such as histamine and other vasoactive agents
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
 E FF E C T S O F U
LT R A S O U N D
When the acoustical stream courses around gas
bubbles, the cell membranes, and its
organelles, eddies form. The eddy current over
the cell membranes causes the release of free-
floating ions and small molecules, increasing
cell membrane permeability that alters the
diffusion rate across the cell membrane.

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
E FF E C T S O F U LT R A S O U N
D : I n j u ry r e s p o n s e
• Cellular Response pr o c e s s
• Increase cell membrane permeability
• Increase cell metabolism and accelerate rate o f
inflammation
• Histamine release
• Inflammation
• Accelerates inflammatory processes and
stimulates cell division

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
E FF E C T S O F U LT R A S O U N
D : I n j u ry r e s p o n s e
• Blood flow pr o c e s s
• Increase local blood f low (cont. US)
• Nerve Conduction
• Increased (thermal effect)
• Muscle Spasm
• Decreased
• Tissue Elasticity
• Increased esp. for collagen rich
tissues
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
E FF E C T S O F U LT R A S O U N
D : I n j u ry r e s p o n s e
• Muscle and p r o c
Tendon Healing e s s
• Increased rate of collagen
synthesis
• Wound Healing

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 O T H E R U S E SO F U S :P
h o n o ph o r e s i s
• Phonophoresis is the application of US
to enhance the absorption of topical
agents through the skin.
• Physical “pushing” of agent through skin
• Due t o increased permeability of dermal
layer
• Usually applied in pulsed mode
• Most commonly, hydrocortisone and analgesics
(such as salicylates and lidocaine) are
administered with phonophoresis.
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
OT HER USES OF U S :L
O W I N T E N S I T YP
• A.k.a LIPUS U LS E D U LT R A S O U
N D medium-frequency (1.5
• the delivery of pulsed,
MHz) US at a much lower intensity (0.03
W / c m 2 ) than conventionally delivered US.
• delivered via a stationary applicator that
contacts the skin through the regular ultrasonic
gel
• primary clinical use is in bone fractures
that show difficulty in healing

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 CONT RAINDICAT I
O N S : C
• Pregnancy - over the abdomen, low back
O N
• Active T. U S
bone g r o w t h at the epiphysis
• Cancer—over a known or suspected area
of malignancy
• Tuberculosis infection—infected tissue,
particularly that under tension
(swelling/abscesses)
• Hemorrhagic conditions—over an area of
active bleeding
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
 CONT RAINDICAT I
ONS: CON
• Impaired circulation
T. U S
• Myositis ossificans—over an area with this
condition
• Deep vein thrombosis or thrombophlebitis—
over an area with this condition
• Acute injury—signs or suspicion of inflammation
• Recently irradiated tissue—skin areas where
radiation therapy has been done
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
 CONT RAINDICAT I
O N S : C O N
• Impaired sensation—nerve damage, so no
sensoryT.feedback about excessive
Uwarmth
S or
burning
• Impaired cognition or communication—no
feedback about excessive warmth or burning
• Skin disease—including damaged and at-risk skin
• Implanted cardiac pacemaker or other
implanted electronics
• Reproductive organs
• Anterior neck
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
 P R E C A U TI O
N: CON
• Plastic or
Cemented implants
T. US
• Spinal cord and superficial or regenerating nerve

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 CONT RAINDICAT I
ONS: PUL S
• Pregnancy—over the abdomen or low back
E D U S
• Cancer—over a known or suspected area
of malignancy
• Hemorrhagic conditions—over an area of
active bleeding
• Myositis ossificans
• DVT

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 CONT RAINDICAT I
ONS: PUL S
• Recently irradiated tissue
E D U S
• Implanted cardiac pacemaker
• Reproductive organs
• Eyes
• Anterior Neck

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
D IA T H
ERMY
 D IA T H
ERMY
• Use of Electromagnetic waves from the radio
frequency or microwave frequency ranges
• 27.12 Hz = Most commonly used aka
Shortwave Diathermy (SWD)
• Microwave diathermy = 2,450 Hz
• Can be delivered continuously or through regular
pulses
• Devices that deliver radio frequency waves t o the
patient at a very low intensity are known as pulsed
electromagnetic fields (PEMF) or pulsed radio frequency
energy.
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
 D IA T H
ERMY

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 D IA T H
ERMY
• can affect deeper tissues of the b o d y than
superficial modalities, such as hot packs
• minimal reflection of waves at tissue interfaces
and on bone

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 S H O R T WAV E D I
ATHERMY
• 2 Types:
• Electric Field
(capacitive method)
• Magnetic Field
(inductive method)

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 S H O R T WAV E D IA T H
E R M Y : C A P A C I T I VE
• Uses an applicator
system that requires
the patient tissues
t o be part of the
capacitor
• Can be applied
contraplanar
or coplanar

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
S H O R T WAV E D IA T H
E R M Y : C A P A C I T I VE

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 S H O R T WAV E D IA T H
E R M Y : I N D U C T I VE
• Requires an inductive
applicator that creates
an oscillating
magnetic field that
induces ” e d d y ”
currents in b o d y
tissues
• Two types of inductive
coil applicator:
• Drums or Sleeves
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
 S H O R T WAV E D IA T H
E R M Y : I N D U C T I VE
1. Drum applicators –
contain a coil-shaped
cable contained
within a rigid plastic
insulator housing
2. Sleeves - designed t o
fit around a b o d y
part, such as the
elbow and forearm,
providing a
circumferential
treatment effect.
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
 M i c r o wav e D I A T
HERMY
• Requires a device called a magnetron
• generates alternating current at a high power level,
which is transmitted t o an antenna housed inside an
emitter (drum or applicator) that directs the
electro- magnetic field t o the b o d y part t o be
treated.

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 E FF E C T S O FD I
ATHERMY : THER
• Goal of most diathermy treatments is t o increase
MAL
the temperature of b o d y tissues
• One key difference is the greater depth of
heating that occurs wit h diathermy compared t o
superficial thermal modalities
• Inductive SWD and PSWD will more effectively
elevate the temperature of deep tissues than
capacitive SWD.

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 E FF E C T S O FD I
ATHERMY : THER
• Reduction of pain
M A L
• Increase tissue elasticity and facilitate
connective tissue flexibility and joint
ROM
• promote healing of soft tissues and bone
•

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
CONTRAIND
ICATIONS

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Department
 PRECA
U TI O N S

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
IN F R A R E D R
A D I A TI O N
 TY P
ES
• Luminous / Non-Luminous
• Wavelength: 770 t o 106 nm lying
between visible light and microwaves
• Further divided into 3 bands:
• IR-A: 770-1400 nm
• IR-B: 1 4 00 - 3 00 0 nm
• IR-C: 3000-10 6 nm

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 T HERMAL
E FF
• Proportional t o the amount of radiation that
penetrates theEtissue
C T which is a function of
power and wavelength of the radiation,
the distance between radiation source and
the tissue, angle of incidence and
absorption coefficient of the tissue.

• Human skin allows maximum penetration of

radiation with a wavelength of 1200 nm while
being opaque with 2 0 0 0 n m and above
Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT
Department
 A P P LI C
A TI O N
• Perpendicular application; 4 5 - 6 0 cm away
from the source

Prepared by: Pethuel M. Pomaloy DLSMSHSI CRS PT

Department
 A D VAN TA
GES
• Does not require contact with patient
• Area being treated can be observed all
throughout the intervention

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Department
 D I S A D VAN
TA G E S
• Not easily localized
• Difficult t o ensure consistent heating in all
treatment areas

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Department
 Q U E S TI O N S ?
T H A N K YO U F O R L
I S TE N I N G !