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Heat Modalities
Chapter 4 (still)
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Heat is commonly classified into 3 major
categories Chemical action associated with cell metabolism
Electrical or magnetic currents as those found indiathermy devices
Mechanical action as found with ultrasound
The application of heat modalities is known asthermotherapy, and methods of heating are
classified as being superficial or deep.
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Superficial heating agents must be capable of
increasing skin temp within a range of 104-113F.
The transfer of heat to underlying tissues occursvia conduction, but superficial heating agents arelimited to a depth of less than 2cm.
The use of heat is indicated in the subacute and
chronic inflammatory stages of injury.
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Because the effects of heat application areessentially opposite to those of cold, its use inthe treatment of acute injuries should be
avoided.
Applying heat to an active inflammatory cycle
will the rate of cell metabolism and
accelerate the amount of hypoxic injury
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Classification of Heating Agents
Superficial
Infrared lamps
Moist heat packs
Paraffin baths Warm whirlpools and/or
immersion
Deep heat
Microwave diathermy*
Shortwave diathermy
Ultrasound
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Local effects of heat application
Vasodilation rate of cell metabolism
capillary permeablilty
delivery of leukocytes
Edema formation Removal of metabolic waste
elasticity of ligaments, capsules, and muscle
Analgesia and sedation of nerves
nerve conduction
muscle tone
muscle spasm
Perspiration
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Some systemic effects of Heat
exposure*
body temp
pulse rate
respiratory rate blood pressure
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General
Indications/Contraindications
Indications
Subacute or chronicinflammatory conditions
Reduction of subacute orchronic pain
Subacute or chronicmuscle spasm
ROM Hematoma resolution
Reduction of Joint
contractures
Contraindications
Acute injuries
Impaired circulation
Poor thermal regulation Anesthetic areas
Neoplasms
Abnormal tissue, such as a
tumor, that grows at theexpense of healthy tissues
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Effects on the injury response
Despite heat and cold produce many of thesame outcomes, decreased pain, for example, thetiming of when to begin using heat modalities is
much more critical If heat is applied too soon in the injury response
cycle, the cell metabolism causes an increase inthe number of cells injured or destroyed becauseof hypoxia.
the inflammatory rate may possiblyextend the acute and subacute stages
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Cellular response
For each of 18F in skin temp, the cells
metabolic rate by a factor of 2-3.
As the cells metabolic rate , so does its
demand for oxygen and nutrients.
As with living organisms that consume
energy, the amount of waste excreted
from the cell as its activity
Also, metabolic rate tissue temp.
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Blood and fluid Dynamics
Response of the body to heat is dilating localblood vessels
The amount of dilation being greater insuperficial vessels than in the deeper vessels
capillary flow results in an supply of
oxygen, nutrients, and antibodies to the
effected area
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The amount of edema is , but the capability
of removing it is greater capillary pressure forces edema and
harmful metabolites from the injured area
permeability aids in the re-absorption ofedema and the dissolution of hematomas.
These wastes can drain into the venous or
lymphatic systems If venous and lymphatic return is not
encouraged, further edema occurs.
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Effects on inflammation
Local application of heat acceleratesinflammation
Soft tissue repair is facilitated through an
accelerated metabolic rate and blood supply
Blood flow must be to encourage the
removal of cellular debris and to delivery
of the nutrients necessary for the healing
of tissues
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oxygen stimulates the breakdown and
removal of tissue debris and inflammatory
metabolites
Nutrients are delivered to the area to fuel
the cells, and there is also an in the
delivery of leukocytes, encouraging
phagocytosis.
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Muscle Spasm and Tissue Elasticity
temperature reduces the primary and
secondary muscle spindles sensitivity to
stretch
the amount of muscle spasm present
Increasing blood flow and reducing local
muscle metabolites further alleviate spasm
Most muscular tissues are not directly
heated by superficial heating agents
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ROM is subsequently improved by theextensibility of collagen and the viscosity
and plastic deformation of tissues This effect alone is not sufficient to
contractures or the elasticity of healthytissues
Neither anterior laxity of the knee norhamstring flexibility has been shown to beaffected by heat modalities alone
Tension, in the form of gentle stretching, isnecessary to elongate muscle andcapsular tissues while the tissues are stillwithin the therapeutic range
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Pain Control
Mechanical deformation and/or chemical irritation ofnerve endings stimulate pain transmission
In acute injuries, the primary cause of pain is themechanical damage done to the tissue in the area.
In the subacute and chronic stage of injury, ischemiaand irritation cause chemical pain from certain chemicalmediators
Mechanical pain is caused by increased swelling and thetension placed on the nerves by muscle spasm
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Mechanical pain is decreased by reducing thepressure on the nerves , thus lessening the pain-
spasm-pain cycle. By encouraging venous and lymphatic return
through the use of elevation and muscle contraction,the swelling is removed, decreasing interstitial
pressureAn increase in temperature leads to a state of
analgesia and sedation in the injured area byacting of free nerve endings.
Nerve fiber are stimulated, blocking thetransmission of pain with a conterirritant effect.
This effect appears to last only as long as the
stimulus of heat is applied
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Dissipation of heat
When therapeutic heat is applied to the body,there is a rapid rise in skin temperature
This rise occurs because energy is beingabsorbed faster than the cool blood delivered tothe area can remove it.
After approximately 10-15 minutes of exposure,the temperature gradient begins to even out.
At that point, the body is able to counteract theenergy being applied by supplying an adequate
amount of blood to cool the area
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At this time, the patient may claim that the modality hascooled down when, in fact, its intensity is unchanged.
When a maximal vasodilation has occurred and theintensity of the treatment stays constant (or increases),the vessels begin to constrict.
The phenomenon, known as rebound vasoconstriction,
will occur approx 20 min into the treatment. This is the bodys attempt to save underlying tissues by
sacrificing the superficial layer.
If the intensity of the tx is too great or if the duration is tolong, burns will result
Mottling of the skin is a warning sign that tissue tempare rising to a dangerously high level. In this case, ghost white areas and beet-red splotches mark
the patients skin
When this occurs, the tx should be discontinued immediately
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Heat vs Cold
How do you know when to use heat and whento use cold??
There are no clear cut answers to this question.
Many articles have given definitive time frames, suchas:
Use cold for the first 24 hrs
And use heat for the next 48 hrs Unfortunately, statements like these are incorrect
and unjustified.
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One of this first statements made in this classwas that the body heals an injury at its own rate.
Not only does this rate vary from person to
person but also it may vary from injury to injuryin the same person
The patients physical and psychological state, as
well as the type and amount of tissue damaged,factor into the time frame for required forhealing.
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The decision-making process is similar to thesteps involved when a pipe ruptures in thebasement of a house
Before bailing out the water and cleaning up themess, you have to stop the leak.
Likewise, before encouraging as increase in the rate
of cell metabolism in an injured area, the activeprocess of inflammation must be calmed down first.
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Remember cold is indicated under 3 conditions In the acute stages of the inflammation reaction
Before ROM exercisesAfter physical activity
Heat application is indicated under 5 conditions
To control inflammation reaction in its subacute orchronic stages
To encourage tissue healing
To reduce edema and ecchymosis
To improve ROM before physical activity orrehabilitation
To promote drainage from an infected site
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Deciding whether to use heat or cold
Does the body area feel warm to the touch?
Is the injured area still sensitive to light or moderatetouch?
Does the amount of swelling continue to increase overtime?
Does swelling increase during activity? Does pain limit the joints ROM? Would you consider the acute inflammation process to
still be active?
Does the patient continue to display improvement withthe use of cold modalities? If the answers to these questions are No heat can safely be
used. As the number of yes answers increases, so does theindication for use of cold
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Paraffin Bath
A paraffin bath contains a mixture of was andmineral oil in the ratio of 7 parts wax to 1 partoil
Melted paraffin is kept at a constant temperatureof 118-126F
Temps for tx given to the lower extremity are
decreased (113-121F) because circulation is lessefficient
Because of its low specific heat paraffin canprovide approx 6 times the amount of heat as
water
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Paraffin is a superficial heating agent used for deliveringheat to small, irregular shaped areas
Fingers Wrist
Hand
Foot
Although its use in sports medicine is limited, it is aneffective method for delivering heat, and this form ofapplication of paraffin is beneficial in chronic
conditions in which ROM is not an essential part of thetx protocol
Arthritis
Chronic inflammatory conditions
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Effects on the IRC
In addition to the standard effects of heat,paraffin increases perspiration in the treated areawhich soften and moisturizes the skin
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Setup and Application
Several methods of application, each with itsown advantages and disadvantages
Paraffin can act as an insulator is allowed to dryon the skin
With this in mind, the amount of heat deliveredcan be adjusted by increasing or decreasing the
wax layers
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Prep for treatment
To avoid contamination of the mixture, thebody part to be treated should be thoroughlycleaned and dried before treatment.
Immersion bathThoroughly clean skin
The patient begins by dipping the body part into theparaffin and removing it. Allow this coat to dry
Dip the extremity into the wax 6-12 times to developthe amount of insulation necessary. Allow wax todry between dips
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Instruct the patient to avoid touching the
sides and bottom of the heating unit becauseburns may result
Instruct the patient who is receiving an
immersion not to move the joints that are inthe liquid. The cracking of the wax will allowfresh paraffin to touch the skin, increasing the
risk of burnsAfter the treatment, scrape off the hardened
paraffin and return it to the unit for reheating,
or discard it
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Pack (glove) Method
The glove method is the safest but least effectiveway for delivering heat to the body with paraffinwax
This method is recommended for those patientswho are in the subacute stages of healing orhave a vascular or nerve condition that wouldpredispose them to burning
The body part may also be elevated during thisform of paraffin application
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Thoroughly clean the body part
Begin treatment by immersing the extremity in the
wax so that it becomes completely covered. Removethe body part and allow wax to dry
Continue dipping for 7-12 times allowing wax to drybetween dips
After the final dip, cover the extremity with a plasticbag, aluminum foil, or wax paper. Then wrap andsecure a terry cloth towel around the area
If indicated, the body part may be elevated.
Following the treatment, remove the towel and theinner layering. Scrape off the hardened paraffin andreturn it to the bath for reheating, or discard it
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Duration of treatment
Paraffin treatments are given for 15-20 minutesand may be repeated several times daily
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Precautions
The sensation of the paraffin is misleading as tothe actual temp of the treatment. The temp ofthe paraffin is sufficient to cause burns, but its
specific heat and thermal capacity requires alonger period of time to transfer the energy
Avoid using paraffin with athletes who arerequired to catch or throw a ball or workers whoare required to maintain a good grip after thetreatment.
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Indications/contraindications
Indications
Subacute or chronicinflammatory conditions
Skin infections Peripheral nerve injuries
before electricalstimulation
Another modality shouldbe considered if the patientlacks temp perception
Contraindications
Acute conditions
Peripheral vascular
disease Areas with sensory loss or
scaring
sunburns
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Next time
Shortwave diathermy
Lab
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Infrared Lamp
Provide radiant energy for superficial heating ofthe skin
They are considered radiant modalities because
no medium is required to transmit energy 2 types
Near infrared (luminous)
Far infrared (nonluminous)Treatment energy is produced by passing an
electrical current through a carbon or tungstenfilament
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The intensity of the treatment is controlled byadjusting the current flow through the filament or
by changing the distance between the lamp and thetissues
Luminous generators produce some degree ofvisible light Which places them on the near end of the infrared
spectrum
Because visible light is present, some of the treatmentenergy is reflected by the surface of the skin
Nonluminous generators do not produce visiblelight Placing them on the far end of the infrared spectrum
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Nonluminous infrared radiation is lesspenetrating than luminous
It has effects at 2mm and at 5-10mm beneath thesurface of the skin
Because nonluminous infrared is lesspenetrating, the skin being treated will feelwarmer than with luminous
Not commonly used in a clinical setting, becauseof the wide range of heating modalities available
However, it was once thought to assist in thehealing of open wounds, such as turf burns but it actually deters the healing process because it
dehydrates the tissues
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Effect on the IRC
Heats the skin almost exclusively
Deeper tissues are heated by conduction todepths up to 1 cm.
Primary physiological effects occur almostentirely in the superficial skin
Hyperemia occurs as a result of increasedcapillary flow and increased capillary pressure
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Setup and application
Warm up the lamp if necessary
To prevent the concentration of heat, clean thearea of any sweat, dirt, or oils, and remove any
jewelry Position the patient in a comfortable manner.
Drape the body part so that only the area to be
treated is exposed If a moist heat treatment is desired, place a
damp terry cloth towel over the area
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Place the lamp so that the source of heat isapprox 24 inches away from the patient. Adjust
the lamp so the energy will strike the tissues at aright angle (inverse square law)
To prevent burns, instruct the patient not to
move Check the patients comfort periodically. The
intensity may be adjusted by moving the lamptoward the skin (increasing temp) or away from
the skin (decreasing temp) Instruct the patient to summon assistance if the
intensity of the treatment becomes too great
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Duration of treatment
20-30 minutes
Given as needed
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Indications/contraindications
Indications Subacute or chronic inflammatory conditions
Skin infections
Peripheral nerve injuries before electrical stimulation Another modality should be considered if the patient lacks temp
perception
Contraindications Acute conditions
Peripheral vascular disease Areas with sensory loss or scarring
sunburns
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Shortwave Diathermy
A deep-heating modiality
Uses energy that is similar to broadcast radiowaves but has a shorter wave length
The energy is delivered to the body is acutally ahigh-frequency alternating current, but lacks theproperties needed to depolarize motor or
sensory nerves.The Federal communication Commission has
reserved the frequencies of 13.56, 27.12, and40.61 for medical use
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Structures with high water content, like adiposetissue, blood, and muscle, are selectively heated
at depths of 2-5cm. Local tissue temp may reach 107, but the
subcutaneous fat layer dissipates a significantportion of the energy
This leads to a secondary heating of thesuperficial muscle layer by heat conducted fromthe adipose tissue
The amount of intramuscular temp increasecompares favorably with that seen duringultrasound application
Producing an increase of more than 7 degrees F
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Because of the relatively large area affected bydiathermy, the deep heating effects are longerlasting than those experienced with ultrasound
However, it is less effective on those personswho have a large amount of subcutaneous fat.
2 units that are commonly used
The condenser unit
The conduction unit
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Condenser unit
Application by way of a condenser unit places thepatient within the actual circuit of the machines unit
2 insulated plates are place on either side of the sitebeing treated
The flow of electromagnetic energy passes through thetissues, which act as electrical resistors and producefrictional heating
Heating occurs at depths of 2.5-5 cm but is uneven
because of differences in the resistance to energytransportation of various tissues When condenser plates or pads are used, heating tends
to occur in the subcutaneous tissues and the superficialmuscle layer
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Induction Unit
Does not place the patient directly in the unitscircuit.
Tissues are affected by radiation emitted form
the electromagnetic field created by theelectrode
The effects of the induction method may heattissues up to 5cm beneath the skin But the primary temp increase occurs in the
superficial and middle muscle layers
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The tissues are place in the electromagnetic fieldby the use of an insulated cable electrode
The cable may be wrapped around the extremity
or coiled flat like a pancake and placed on theskin
Another method ahs the cable in a self-
contained drum
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Effects on the IRC
Heating properties are similar to those of otherforms of heat application
But tend to occur deeper within the tissues and are
based on the treatment intensity
During vigorous heating skin temp in the treatedarea increases 4.3 degrees, and the intra-articular
temp of the knee increases 2.5 degrees. Blood flow in the deeper tissues increases, and
fibroblastic activity, collagen deposition, and
new capillary growth are stimulated.
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Muscle spasm is reduced by the sedation ofsensory and motor nerves
As with all heat applications, there is a local
increase in cellular metabolic rate and inperspiration, which must be removed during thetreatment
General prep
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General prep
There must be no metal within the immediate treatment
area. The presence of metal will collect and concentratethe energy from the treatment in the same manner thatan antenna collects radio waves
For personal safety, the clinician should remove any
rings, watches, bracelets, and so on Cover the area to be treated with a dry terry cloth towel
to absorb perspiration. A portion of the treatment areamust remain visible to check for burns during
treatment. Avoid any moisture buildup during thetreatment because water tends to collect heat. Theintensity must be turned to zero before drying thearea
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Condenser method
Plate setup
Adjust the plates so that they are parallel to the skin,1 inch above the patient. On most units, it is
essential that both plates be placed at an equaldistance above the tissue. This adjustment can beaccomplished by using a spacer, such as a piece of
wood. Place the spacer on the patient and lower the
plate until the plate and the spacer touch. Removethe spacer and repeat for the other plate. The spacermust be removed before the treatment is started.
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Consult the users manual for the minimum andmaximum distance allowed between the condenser
plates. Condenser pad setup
Cover the area to be treated with six layers oftoweling
Place the condenser pads on the toweling. If thepads are used on the same side of the body, placethem as far apart as possible. If they are used on theopposite side of the body part (anterior or posterior,
medial or lateral), avoid having the patient lie on thepad
Secure the pads in place with sandbags or somethinglike that.
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Induction Method
Cable setup
Place six layers of toweling around the body part
Using spacers, wrap the cable around the body part,
leaving a minimum of 1 between the coils. Theleads to and from the coil should be of equal length
Secure the cable ends so that they do not touch each
other, the patient, or the shortwave unit itself
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Coil setup
Using spacers, form a coil of at least three circles
approximately equal to the area being treated. Thereshould be a minimum of 1 between the circles, and
the leads should be of equal length. Use an insulatoror 1 of padding to separate the end of the inner coil
from the coil itself
Insulate the skin with at least 6 layers of toweling
Place the coil on the patient and lightly secure in
place with sandbags Position the leads so they do not come in contact
with each other, the patient, or the unit.
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Drum setup
Position the drum approx .5-1 above the toweling.There is a direct relationship between the distance of
the drum from the patient and the intensity ofenergy required for the treatment.
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Application
Turn the unit on: allow it to warm up ifnecessary
Some units must be turned to allow for maximal
energy transfer. If tuning is necessary, consultthe users manual and follow the manufacturers
instructions.
Instruct the patient not to move until themachine is turned off.
Increase the intensity until the athlete feels mild
warmth
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If the electrodes must be moved or if it becomesnecessary to dry the area, return the intensity tozero before making any adjustments
Check patient regularly. Observe the skin forsigns of burns, and inquire as to any unusualsensations. Adjust as necessary
After the treatment, return the intensity dial tozero and shut off the unit.
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Duration of treatment
At moderate intensities, treatments may be givenfor 20-30 minutes and may be repeated asneeded for 2 weeks. When higher treatment
temps are used, decrease the duration oftreatment and apply on alternate days.
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Precautions
Many states require a physicians prescriptions
for the application of SWD.
Never allow the cables to touch each other. This
may create a short circuit
The skin exposed to the treatment must alwaysbe covered by at least .5 of toweling
Do not allow perspiration to collect in thetreatment field
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Never allow the skin to come into direct contactwith the heating unit or cables. Severe burns
may result. Excessive amounts of adipose tissue overlying
the treatment area can result in overheating theskin
Overheating of the patients tissues may causetissue damage without any immediate signs.Deep-tissue burning can cause destruction of
muscular tissue of subcutaneous fat necrosis.A deep, aching sensation may be a symptom of
overheating the tissues
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It is difficult to heat only localized areas. Waterpathways within the tissues dissipate heat formed in thetreated area
The electromagnetic energy is not localized to thetreatment area, radiating 2 to 3 feet from the source of
continuous SWD and 2 feet from the source of pulseddiathermy. Clinicians may be placed in the field of thisscattering radiation, possibly overexposing them todiathermy. A distance of 3 feet from the source of the
energy should be maintained to ensure the operatorssafety.
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Indications
Joint inflammation (bursitis, tendinitis, synovitis) Usewith caution as the deep heating may cause collagendestruction within the joint.
Large areas, such as the paraspinal muscles, that cannotbe effectively heated through other methods because ofthe size of the target tissues
Fibrositis
Myositis
Subacute and chronic inflammatory conditions in deep-tissue layers
osteoarthritis
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Contraindications
Ischemic areas: the increased metabolic rateincreases the need for oxygen, causing furtherhypoxia
Peripheral vascular disease Metal implants or metals such as jewelry. The
metal collects and concentrates the energy,potentially causing burns
Perspiration and moist dressings. The watercollects and concentrates the heat
T d h h i l di
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Tendency to hemorrhage, includingmenstruation.
Cancer Fever
Sensory loss
Cardiac pacemakers
Areas of particular sensitivity
Epiphyseal plates in children, the genitals, sites of
infection, the abdomen with an implantedintrauterine device (IUD), the eyes and face