The Effect of Heat on Tissue Extensibility: A Comparison of

Deep and Supercial Heating

Val J. Robertson, PhD, Alex R. Ward, PhD, Peter Jung, BPhysio
ABSTRACT. Robertson VJ, Ward AR, Jung P. The effect of
heat on tissue extensibility: a comparison of deep and super-
cial heating. Arch Phys Med Rehabil 2005;86:819-25.
Objective: To compare the effects of deep heating (short-
wave diathermy [SWD]) and supercial heating (hydrocollator
packs) on tissue extensibility.
Design: A double-blind, repeated-measures study. Possible
effects of sex and intervention order were controlled.
Setting: A clinical laboratory.
Participants: Twenty-four subjects with no neurologic or
musculoskeletal pathologies affecting their lower limbs.
Interventions: Three intervention conditions: deep heating
(SWD), supercial heating (hot packs), and no heating were
applied in preallocated order to each subject at least 36 hours
apart.
Main Outcome Measures: Ankle dorsiexion in weight
bearing was measured by using an inclinometer to ascertain
changes in the extensibility of the calf muscles and associated
soft tissues.
Results: Deep heating increased the range of ankle dorsi-
exion by 1.81.9. The change in ankle dorsiexion after
supercial and no heating was 0.71.5 and 0.11.0,
respectively.
Conclusions: Deep heating, in the absence of stretching,
increases tissue extensibility more than supercial heating or
no heating. Supercial heating is more effective than no heat-
ing, but the difference was not statistically signicant.
Key Words: Diathermy; Range of motion, articular; Reha-
bilitation; Short-wave therapy.
2005 by American Congress of Rehabilitation Medicine
and the American Academy of Physical Medicine and
Rehabilitation
H
EATING HAS LONG BEEN used clinically to increase
tissue extensibility.
1
Both deep and supercial methods of
heating are used for this purpose.
2,3
Our purpose in this study
was to compare the effects on tissue extensibility of deep
heating (short-wave diathermy [SWD]) and supercial heating
(hydrocollator packs).
The main methods of producing deep heating are ultrasound
and SWD.
2
An important difference between these methods is
that SWD can heat a larger area and volume of tissue than
ultrasound in the same time period. Studies of heating at 3-cm
depth by using SWD identied temperature increases of 4 to
4.6C.
4,5
By contrast, most methods of supercial heating can heat
large areas but smaller volumes of tissue because the depth of
penetration is less. One method is to apply hot packs, a silicate
gel pack heated to 75 to 80C in a water hydrocollator.
2
At
3-cm tissue depth, the expected muscle temperature elevation
is 1C,
6
considerably less than that of SWD. This suggests that
supercial heating is unlikely to effect changes in extensibility
in more deeply located structures,
7
if the changes are directly
caused by the heating and not by indirect (eg, neurally medi-
ated) effects.
The other difference between the 2 heating types is that
SWD provides a constant rate of energy delivery. By contrast,
hot packs start cooling immediately after they are removed
from the hydrocollator.
8
Heating a large proportion of the
relevant tissues for at least 5 minutes at the required level is
said to be necessary to increase extensibility.
5
The temperature
required is above 40C,
9
possibly between 40 and 45C.
10
Clinically, a 3 to 4C increase in temperature, maintained for
at least 5 minutes, is considered safe and sufcient to signi-
cantly increase extensibility.
11
Existing Research
We did an extensive literature search to identify whether
deep or supercial heating was more effective at increasing
tissue extensibility. We found only 1 study
12
that directly
compared both types of heating. Knight et al
12
measured ankle
dorsiexion to identify changes in calf muscle extensibility in
response to a stretching program, applied together with ultra-
sound (deep) or hot packs (supercial heating) for 2 of the 5
groups tested. The percentage change in range with stretch and
deep heating indicates that ultrasound and stretch is more
effective than supercial heating and stretch. The confounding
factors in the Knight study are the concurrent use of a stretch-
ing protocol and the method used to apply the hot packs. The
extent of change attributable to heat is an indirect measure,
derived by comparing the results of the heating and stretch
groups and the stretch-only group. Indicators of the extent of
heating from the hot packs were not presentedeither the
expected level of subject-perceived heating or the distance of
the pack from the skin. The stated depth of 9 layers of toweling
is not sufciently informative because the towel thickness is
unstated and the amount of compression would have a major
inuence on the rate of heat transmission. Both indicators,
thickness and compression, would be needed to replicate the
procedure.
Because only 1 study was identied that compared the
effects of deep and supercial heating on extensibility, we also
evaluated the 12 in vivo human studies we found that investi-
gated either type of heating. We quickly identied difculties
in comparing ndings because of differences in the protocols
used. For example, the number of occasions on which inter-
ventions was applied varied considerably. Two studies
1,13
re-
ported 25.2% and 29.6% increases in hamstrings extensibility,
respectively, after 5 consecutive days of SWD treatment and
hamstrings stretches and another study
14
reported a 7.5% in-
crease after 14 treatments with pulsed SWD and calf stretches.
Three other studies
15-17
obtained smaller increases in ham-
From the Central Coast Health and University of Newcastle, NSW, Australia
(Robertson); and the School of Physiotherapy (Jung); and Department of Human
Physiology and Anatomy (Ward), La Trobe University, Victoria, Australia.
No commercial party having a direct nancial interest in the results of the research
supporting this article has or will confer a benet on the author(s) or on any
organization with which the author(s) is/are associated.
Reprint requests to Alex Ward, PhD, Dept of Human Physiology and Anatomy, La
Trobe University, Victoria 3086, Australia, e-mail: a.ward@latrobe.edu.au.
0003-9993/05/8604-9171$30.00/0
doi:10.1016/j.apmr.2004.07.353
819
Arch Phys Med Rehabil Vol 86, April 2005
strings extensibility, between 4.4% and 20.7%, after 1 session
of supercial heating and stretching. It appears that repeated
treatments generally produce greater changes in extensibility,
but it is not clear what contribution heating, as distinct from
stretching, makes to the increase in extensibility.
Another limitation is the investigation of different joints and
muscle groups. Two studies
18,19
that investigated deep heating
on calf muscle extensibility obtained an average increase
of 3.8 in ankle dorsiexion range of motion (ROM). Five
studies
6,15,17,20,21
examined the effects of supercial heating on
hamstrings extensibility and obtained an average increase of
11.5 in hip exion range. Although, as noted earlier, different
studies are not strictly comparable, the indication is that super-
cial heating is more effective at increasing extensibility. How-
ever, ankle dorsiexion has a smaller range than hip exion.
When the results are expressed as percentage change in exten-
sibility, they suggest that deep heating is more effective, with
the increases ranging from 29.6% to 55.3%,
18,19
compared with
4.4% to 20.7% after supercial heating.
6,15,17,20,21
This shows
the importance of using the same or comparable regions or
using percentage changes for comparison.
In summary, we were unable to identify any direct compar-
isons of the effects of deep and supercial heating on tissue
extensibility. Most studies investigated only 1 form of heating
and used a concurrent stretch protocol. This means the effects
of heating per se can only be extrapolated, an indirect method
of ascertaining any effects it might have. A 1970 study
22
not
reviewed above investigated the effects of heating on rat ten-
don length. The study found that heating (to 45C in a water
bath) without stretch did not contribute to the extensibility of
the tendon. Although these ndings cannot be directly extrap-
olated to an in vivo human clinical context, they suggest that
heating contributes little without concurrent or repeated longi-
tudinal stretching.
Our general aim in this study was to compare the effects on
tissue extensibility of SWD and hot packs. To identify the
contribution of heating to changes in extensibility, a concurrent
stretching program was not used. The tissue extensibility out-
come measure used was weight-bearing ankle dorsiexion.
This provided an indication of changes in extensibility of the
calf muscles and associated structures and has been shown to
be highly reliable when using an inclinometer (intratester in-
traclass correlation coefcient [ICC].98
23
and ICC.94
19
).
Our specic aims were as follows: (1) to determine if heating
produces a signicant increase in the extensibility of the calf
muscle and associated structures and (2) to establish if there is
a greater increase in calf muscle extensibility after deep or
supercial heating.
METHODS
We used a repeated-measures design to compare the effects
of deep and supercial heating on calf muscle extensibility.
Before the study, ethics approval was obtained from the Hu-
man Ethics Committee, Faculty of Health Sciences, La Trobe
University, Australia. The study was conducted in a clinical
laboratory at La Trobe University.
Participants
Twenty-four subjects (12 men, 12 women) participated.
They were students with an age range from 19 to 31 years
(mean standard deviation [SD], 21.52.5y). Potential sub-
jects were excluded if: they had any current musculoskeletal or
neurologic injuries, pain, or conditions affecting either lower
limb; any subcutaneous metal implants in their lower limbs; an
inability to distinguish a hot from a cold object applied to the
skin of their lower limbs; any medical condition that could be
exacerbated by therapeutic heating; pregnant or possibly preg-
nant; or had a cardiac pacemaker or any other form of indwell-
ing stimulator or pump.
24
Experimental Design
Subjects attended 3 sessions and received a different inter-
vention (deep, supercial, no heating) each time, with the
sessions at least 36 hours apart to minimize any carryover
effects. The 6 possible orders of the 3 interventions were
predetermined (4 sets 6 orders) and 1 placed in each of 24
sealed envelopes. Two sets of envelopes were marked M for
males (n12) and 2 sets with an F for the females (n12).
These procedures enabled randomization, ensured a sex bal-
ance, and countered any possible order effects. Subjects se-
lected an appropriate envelope at the rst session.
Procedure
Each subject started with 2 preintervention measurements of
the range of dorsiexion on his/her preferred kicking leg. One
investigator obtained all pre- and postintervention ankle dorsi-
exion measurements and was blinded to each subjects inter-
vention order throughout.
At each of the 3 interventions, subjects were asked to lie
supine on a wooden treatment plinth in the laboratory. Inves-
tigator 1 and an assistant administered all interventions, but
remained unaware throughout the study of the subjects dorsi-
exion measurements obtained by investigator 3. Throughout
all 3 interventions, the weight of the test leg was supported by
rolled towels placed under the knee and the heel. Immediately
after 15 minutes of each intervention condition, subjects
walked the approximately 5m to an adjacent area where inves-
tigator 3 again measured their range of dorsiexion twice.
Subjects preferred legs (21 right, 3 left) were tested. The
protocols used for each intervention and measurement are
described later.
Deep Heating
After the 2 preintervention ankle dorsiexion measurements,
subjects lay supine on a wooden plinth in the treatment room.
With the test leg supported by rolled towels, the 2 capacitive
SWD pads were positioned parallel and close to the lower leg
and perpendicular to the top of the plinth. The 2 capacitive
electrodes were encased in thick rubber (1217cm each) and
were separated from subjects skin by two 1-cm purpose-
designed felt pads. Investigator 1 or an assistant placed the 2
pads below the distal popliteal fossa region, longitudinally on
either side of each subjects test leg. A rolled towel was placed
between the 2 pads on the anterior border of the tibia to
maintain separation. Towels also secured the 2 pads against the
leg and separated both the pads and the subjects skin from the
plinths surface.
The SWD machine
a
was then turned on. Each subject was
instructed to remain in the same position to prevent movement
of the 2 capacitive pads and was informed that the level of
heating would be comfortably warm. The output of the SWD
machine was increased until the subject reported feeling a
comfortable warmth. If the level of perceived heating changed
during the application, the machines output was adjusted ap-
propriately to ensure that the heating remained comfortably
warm. After 15 minutes of continuous heating, the machine
was turned off and the towels and capacitive pads removed.
The subject was then instructed to stand up slowly and walk to
the adjacent measuring area.
820 HEATING AND TISSUE EXTENSIBILITY, Robertson
Arch Phys Med Rehabil Vol 86, April 2005
Supercial Heating
Each hot pack was preheated for at least 24 hours in a
hydrocollator at 78 to 80C. After the 2 preintervention ankle
dorsiexion measurements, subjects again lay supine on the
plinth, and the test leg was supported by rolled towels to limit
pressure on the underlying hot pack. Again, subjects were
informed that the heating was only to be comfortably warm.
Investigator 1 or an assistant placed the 2530cm hot pack,
b
covered by a 1 to 2cm hot-pack cover
b
and 2 layers of toweling,
under each subjects lower leg, covering the posterior surface
from the popliteal fossa distally.
Subjects were instructed to remain in the same position and
not to lift the test leg off the hot pack. If the level of perceived
heating increased to more than comfortably warm, more tow-
eling was added immediately to ensure the heating remained
only comfortably warm. The hot pack was removed after
15 minutes, and the subject was instructed to stand up slowly
and walk to the adjacent measuring area.
No Heating (Control)
During the no heating intervention, subjects remained supine
on the plinth after the 2 preintervention ankle dorsiexion
measurements were taken. The weight of their test leg was
supported by rolled towels, and they were asked to remain
lying in the same position. After 15 minutes of no heating, the
subject stood slowly and walked to the adjacent measuring
area.
Ankle Dorsiexion Measurements
Calf muscle extensibility was measured as the weight-bear-
ing ankle dorsiexion ROM by using a SmartTool inclinom-
eter.
c
Intratester ICC
3,3
and intertester ICC
2,3
for weight-bear-
ing ankle dorsiexion ROM measurements by using an
inclinometer have been shown to be .98 and .97, respectively,
23
and Draper et al
19
reported an intratester ICC of .94.
The inclinometer was calibrated according to the manufac-
turers specications: it was placed on a horizontal surface
(angle, 0.0) and zeroed. For foot placement, investigator 3
used a custom wooden wedge 90cm from a waist-high ledge.
The wedge was approximately 45cm long and had an inclina-
tion of 15.2 so that each subjects ankle was in some initial
dorsiexion. It also had 2 rows of tape running up the slope to
ensure consistent foot and heel placement.
The measuring process was explained and shown to each
subject, who then positioned his/her test leg so that the heel and
the medial border of the foot were within the taped lines on the
wedge. Subjects were told to place their other foot comfortably
in front, on the wedge, and to rest both hands on the ledge for
balance. The tibial tuberosity of the test leg was marked with a
whiteboard marker to place the inclinometer. The subject was
then instructed, Keeping your test knee fully straightened, and
without lifting your heel off the wedge, roll your ankle into
dorsiexion by advancing the front of your thigh over the
middle of your foot until you feel a stretch in your calf
muscle. These instructions were intended to minimize any
rotation in the ankle and leg.
25,26
Investigator 3 then placed the inclinometer, reading 0.0, on
the subjects shin with the top end on the mark on the tibial
tuberosity, to measure the angle between the anterior border of
the tibia and the vertical. To prevent extraneous movements
during the measurement, investigator 3 held each subjects heel
with 1 hand and used the gentle pressure of the inclinometer on
the anterior border of the tibia to help hold the knee in full
extension.
The investigator then said, Keep dorsiexing your ankle
until you cannot go any further. When the subject reached that
point, he/she was asked to remain in that position while the
investigator took this measurement. Subjects were cautioned to
keep the heel down on the wedge and to keep the knee fully
extended. The hold button on the inclinometer was released
until a stable angle was displayed, which was then held and
recorded. The subject was then told to rest. The procedure
lasted less than 10 seconds. The inclinometer was placed back
on the ledge and zeroed. The procedure was repeated within
30 seconds to obtain 2 preintervention measurements, after
which the preallocated intervention was applied.
After each intervention, the subject reentered the measuring
area and stood facing forward. This prevented the investigator
from seeing the subjects calf region and thereby possibly
identifying the source of any visible erythemal patterns. The
investigator used the preintervention measuring protocol, again
recording 2 ankle dorsiexion measurements within 30 sec-
onds. The subject was then asked to return for any remaining
test sessions.
Questionnaire
After all 3 interventions, subjects completed a questionnaire
that asked about their levels of sport or exercise involvement
and calf stretching activities during the study. They were also
asked to comment on the 2 types of heating they had received
in the study.
Data Analysis
All statistical analyses were performed by using the SPSS,
version 11, software package.
d
Before analysis, the 2 pre- and
2 postintervention ankle dorsiexion ROM data sets for each
intervention were separately averaged to reduce error. The
intervention outcomes (change in ankle dorsiexion ROM)
were calculated as the difference between the averaged post-
and the averaged preintervention ankle dorsiexion measure-
ments.
A 2-factor repeated-measures analysis of variance (ANOVA)
was performed with the 3 interventions as the repeated-measures
factor and sex as the group factor. The aim was to establish
whether there were statistically signicant between-interventions
and between-sex effects on ankle dorsiexion ROM. An level of
.05 was used for the ANOVAtest. Intervention outcome data were
rst tested for normality by using quantile-quantile (Q-Q) plots.
Where Q-Q plots indicated that the data were not normally dis-
tributed, a Huynh-Feldt correction factor was used in the sub-
sequent ANOVA.
The ANOVA identied a signicant between-interventions
effect on ankle dorsiexion ROM, so we performed post hoc
testing. Paired t tests were used to identify which interven-
tion(s) signicantly increased ankle dorsiexion ROM. Be-
cause 3 post hoc t tests were required for this analysis, we used
a Bonferroni adjustment of the acceptable P value to reduce the
risk of a type I error. Signicance was therefore only accepted
if a P of .05/3.017 was achieved. A problem with using a
Bonferroni adjustment is that the risk of a type II error is
increased and must be considered for each of the calculated P
values that exceed .017. Further post hoc testing was not
required because the absence of a between-sex effect was
indicated by the ANOVA. We used a scatterplot graph of
intervention outcomes after deep versus supercial heating to
examine intrasubject variation in response to heating, and a
Pearson r value was calculated.
Answers to the questionnaire were analyzed with scatterplot
graphs to determine the Pearson r values between the interven-
821 HEATING AND TISSUE EXTENSIBILITY, Robertson
Arch Phys Med Rehabil Vol 86, April 2005
tion outcomes after deep heating versus subject participation in
sports or exercise (duration frequency) and calf stretches
(duration frequency) performed during the study. Analyses
of the intervention outcomes after supercial and no heating
were omitted because the earlier post hoc t tests did not show
any statistically signicant effects.
RESULTS
Between-Sex Effects
The mean change in ankle dorsiexion ROM in men after
deep heating was 1.82.2 and in women it was 1.81.7;
after supercial heating, it was 0.61.4 and 0.81.5, re-
spectively; and after no heating 0.10.7 and 0.21.2,
respectively (table 1). The 2-way repeated-measures ANOVA
indicated that between-sex differences were negligible
(F
1,11
.002, P.964), as was the intervention by sex interac-
tion. Given this, all data for men and women for each inter-
vention were combined for all subsequent tests.
Intervention Effects
The mean change in ankle dorsiexion ROM in all subjects
after deep heating was 1.81.9 (95% condence interval
[CI], 1.02.6); supercial heating, 0.71.5 (95% CI, 0.1
1.3); and no heating 0.11.0 (95% CI, 0.5 to .3).
These changes are equivalent to a 5.2% increase after deep
heating, 2.0% after supercial heating, and 0.4% with no
heating. Figure 1 shows the median change and the interquar-
tile range (IQR) and outliers for the combined data for men and
women for each intervention.
The 2-way repeated-measures ANOVA identied a statisti-
cally signicant between-interventions effect on intervention
outcome (F
1.93,21
9.643, P.000).
Post hoc testing identied a statistically signicant differ-
ence (P.017) in 2 of the 3 comparisons. A paired t test
indicated that the difference in intervention outcome after deep
and supercial heating was statistically signicant (t
23
2.638,
P.015), meaning that deep heating increased ankle dorsiex-
ion ROM more than supercial heating. A second t test also
indicated that the difference in intervention outcome after deep
and no heating was also statistically signicant (t
23
3.876,
P.001). A third t test showed that the difference between
supercial and no heating did not reach the Bonferroni-ad-
justed signicance level (t
23
2.208, P.038).
The relatively large SD associated with each outcome mea-
sure raised the question of whether this was because of be-
tween-subject differences in what was regarded as comfort-
able warmth. This could have resulted in a wide variation in
the outcome measure due to different amounts of actual heat-
ing. If so, a subject who had a greater than average increase in
ankle dorsiexion ROM after deep heating should also have a
greater than average increase after supercial heating. A scat-
terplot graph (change in ROM because of SWD vs change in
ROM because of hot-pack heating) showed only a slight pos-
itive correlation, with a Pearson r of .24. Thus, between-subject
variation in perception of comfortable warmth cannot account
for the variance observed (r
2
5.8%).
The Questionnaire
We used the responses to the questionnaire to examine
whether there was any correlation between engagement in
sports or exercise and the change in ROM. Fifteen of the 24
subjects participated in vigorous sport or exercise activity
during the study. An index of activity was calculated by mul-
tiplying the duration of the activity (in minutes) by the daily
frequency, excluding daily functional activities such as walk-
ing. A scatterplot graph indicated a very small positive corre-
lation (Pearson r.17). A similar analysis was performed for
the 11 of those 15 who did calf muscle stretching during the
study. A scatterplot graph (calf stretching duration fre-
quency vs change in ROM) showed a very small negative
Table 1: Ankle Dorsiexion ROM in Men and Women
Intervention
(heating)
Preintervention
Measure
P for 2
Preintervention
Measures
Postintervention
Measure
P for 2
Postintervention
Measures
Difference
Post to Pre
Deep
Men 36.75.8 .66 38.56.8 .12 1.82.2
Women 33.34.2 .44 35.14.6 .06 1.81.7
Supercial
Men 36.95.8 .67 37.55.9 .62 0.61.4
Women 33.94.4 .84 34.74.8 .58 0.81.5
No heating
Men 38.06.3 .36 37.96.3 .07 0.10.7
Women 34.43.3 .52 34.23.6 .82 0.21.2
NOTE. Values are mean degrees SD. Figures are rounded to 1 or 2 decimal place(s).
Fig 1. Boxplots show the median, IQR, and outliers for the com-
bined data for each intervention: supercial, deep, or no heating.
822 HEATING AND TISSUE EXTENSIBILITY, Robertson
Arch Phys Med Rehabil Vol 86, April 2005
correlation (r.13). Thus, engagement in sport or exercise
activity cannot account for the variance observed.
Analysis of the questionnaire of subjects preferences for
either form of heating showed that 9 preferred supercial
heating, 9 favored deep heating, and 6 had no preference. Most
had a preference but did not believe 1 type of heating provided
more comfort or exibility. Subjects generally reported that
supercial heating felt warm supercially, provided con-
centrated heating in the calf area and was comfortable. They
indicated that deep heating felt comfortable and provided
total, consistent heating.
DISCUSSION
This study had 3 major ndings: (1) heating the calf region
increased the ankle dorsiexion ROM more than no heating,
(2) deep heating was more effective than supercial heating,
and (3) sex and involvement in sports or exercise had little
effect on the outcome.
Heating Increases ROM
This study has claried the extent to which heating contrib-
utes to changes in tissue extensibility. Heating a large area
produced increases of 5.2% in the ROM for deep heating, 2.0%
for supercial, and 0.4% for no heating. This indicates the
value of deep heating before joint or tissue mobilizing.
The present nding contrasts with that of Lehmann et al
22
that heating does not contribute to the extensibility of collag-
enous tissues. An important difference is that in our study, we
heated not just connective tissue but also muscle and nerve,
which implies that the extensibility increases we observed were
either a result of changes in the mechanical stiffness of muscle
tissue, changes in afferent nerve ber activity, or a combination
of these factors.
Previous studies of deep heating effects have not consis-
tently identied changes in tissue extensibility. Given the use
of pulsed SWD, this is perhaps not surprising.
1,13
Pulsing the
SWD output can reduce the average power considerably. Our
results show that heating a volume of tissue to a comfortably
tolerated temperature can increase extensibility. By contrast,
pulsed SWD, with its lower average power output, is unlikely
to raise tissue temperatures sufciently to alter extensibility
unless it has either a very high duty cycle or peak power output.
The other type of deep heating previously investigated
and shown to increase tissue extensibility is 1MHz ultra-
sound.
12,18
The size of the applicators (typically 5cm
2
) and
the method of application (circular movement over a rela-
tively small area) would result in only a small proportion of
the relevant tissue being heated when large tissue masses
such as the hamstrings or calf muscles are treated. That both
studies did demonstrate a change is suggestive of an indi-
rect, neurally mediated effect.
Other studies
19,26
of the efcacy of ultrasound failed to
identify any signicant changes in extensibility. Both used
3-MHz frequency ultrasound, and this has a considerably lower
penetration depth than 1-MHz frequency ultrasound. Conse-
quently, the volume of tissue affected is likely to be less than
if 1-MHz frequency ultrasound or SWD were used.
Previous studies
16,17
of supercial heating have generally
not identied changes in extensibility. The exception was a
study
21
that did not obtain pretreatment measurements of
ROM.
Deep Heating Compared With Supercial Heating
The second main nding was that deep heating increases
tissue extensibility more than does supercial heating. This is
consistent with the different depth efciency of capacitive
SWD and hot packs. The higher depth efciency of SWD
means it would have heated a larger volume of tissues and
uids within the calf region than is possible using hot packs.
Some heating would be direct and some indirect because of
warmed blood carrying heat to adjacent areas that are not
directly heated.
The lesser effect of supercial heating suggests that the
contribution of any skin response, or reex vasodilatation as-
sociated with heating the skin, is likely to have been minimal.
Subject-Related Factors
The large SDs associated with each outcome measure raised
questions about the possible sources of variation. The rst
possible source we examined was sex. However, the groups
were sex balanced and changes in extensibility for women and
men were indistinguishable. Another possible source of differ-
ence concerned subjects physical activities during the study.
Analysis showed very low correlations between levels of ac-
tivity and muscle stretching and the changes in extensibility
found in the study. Thus, the large SDs are not explained by
physical activity or stretching participation.
Another source of variation may have been related to the
order of the interventions. This is unlikely because they were
balanced and allocated in a randomized order.
Measurement error is also a possible explanation of the large
variation. When the preintervention ankle dorsiexion mea-
surements are subtracted from those taken postintervention to
obtain the change in ankle dorsiexion, the errors in both are
combined. This means that even though the individual ROM
measurements may contain a small percentage error, when the
change in ROM is calculated the percentage error is much
larger.
Study Strengths and Limitations
Despite the range of possible sources of inter- and intra-
subject error, our present study has major strengths. The rst is
that the same investigator obtained all ankle dorsiexion mea-
surements while blinded to each intervention order throughout.
This eliminated any risk of bias in the measurement procedure.
Similarly, the same researchers applied all heat interventions
and remained unaware throughout about the dorsiexion mea-
surements. In addition, use of a randomized subject allocation
designed to balance possible sex and order effects further
increases the credibility of our results.
The main limitation of the study was our use of test subjects
who initially had a normal ankle dorsiexion ROM. Subjects
average preintervention weight-bearing ankle dorsiexion
measurement was 35, which is higher than the 28 that is
generally accepted as normal.
19
This limits the extent of
changes that could have been identied irrespective of the
efcacy of heating in increasing tissue extensibility. Our nd-
ings therefore suggest that the changes to extensibility contrib-
uted by heating may be considerably higher and more clinically
signicant than this study could have shown. This indicates the
need for more research with subjects with joint movement
restrictions and tightness of associated soft tissues.
A potential limitation is that we assumed that SWD produces
greater heating at depth than supercial heating, but we did not
actually monitor deep-tissue temperature. Whether our as-
sumption is true could have been determined by temperature
measurements by using thermistors inserted with a syringe, but
the measurements obtained would be unreliable because the
metal thermistor and its wires would produce excessive heating
of adjacent tissue with SWD. Had the thermistors been re-
823 HEATING AND TISSUE EXTENSIBILITY, Robertson
Arch Phys Med Rehabil Vol 86, April 2005
moved and reinserted to avoid this consequence, discomfort
and tissue damage would have resulted, potentially compro-
mising ROM measurements.
Another potential limitation of the study was the sample
size. The comparison between the effects of supercial and no
heating on the intervention outcome did not achieve statistical
signicance at the Bonferroni-adjusted P value of .017. The P
value obtained (.038) suggests this was because of a small
effect size (a type II error), rather than a lack of any real
difference. Power calculations indicate that a sample size of 30
subjects would have been needed to show signicance at the P
less than .017 level. To enable randomization and sex and order
balancing, this would have meant 36 subjects (6 orders 6
repeats). This lack of power; however, is not a real limitation
from a clinical perspective. A valid conclusion is either that
supercial heating is ineffective or that the effects are small.
By contrast, the effects of deep heating are large enough to be
signicant.
A further possible limitation concerns the methods used to
deliver energy. We used the capacitive method of SWD. The
inductive method can heat deeper tissues more effectively.
2
We
used a hot pack applied to the posterior surface of the lower
leg. Had the hot pack been wrapped around the medial and
lateral calf region, a greater effect may have been found. This
suggests further comparisons modeled on this study to test
whether different methods of application might produce greater
changes in extensibility.
Clinical Implications
This study showed a small, yet statistically signicant,
change in ankle dorsiexion ROM after deep heating in a
sample of healthy, active, university students. A possible clin-
ical implication of this nding is that physiotherapists may
benet by using SWD to increase extensibility in patients with
muscle tightness, contractures, and soft-tissue injuries such as
muscle strains. Our results also suggest the need to investigate
other types of deep heating. The options include inductive
SWD, microwave (frequency of 434MHz), and 1-MHz fre-
quency ultrasound applied at different intensities for different
durations.
Currently, SWD is currently not frequently used in clinical
practice.
27,28
The SWD machine is expensive and introduces
safety issues such as an increased risk of overheating and
causing tissue damage, especially to patients with metal im-
plants.
29
Given the trend to a greater use of implanted metal
and indwelling stimulators and pumps in modern surgical prac-
tice, use of SWD is likely to remain relatively low. Our study
results, however, indicate that when it is used, this form of deep
heating can signicantly increase tissue extensibility.
CONCLUSIONS
We found that SWD is more effective at increasing calf
muscle extensibility than are hot packs. The changes in calf
muscle extensibility were relatively small because our subjects
were active and had little room for improvement in range.
However, the changes in extensibility after SWD, compared
with hot packs treatment or no heating, were statistically sig-
nicant. Our ndings imply that SWD could be used clinically
to increase tissue extensibility in the treatment of musculoskel-
etal pathologies resulting in scarring or the adaptive shortening
of tissues.
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Suppliers
a. Ultratherm 808i Shortwave Diathermy machine; Siemens Aktieng-
esellschaft, UB Med, Henkestr 127, 852 Erlangen, Germany.
b. Chattanooga Group Inc, 4717 Adams Rd, Hixson, TN 37343.
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Australia.
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825 HEATING AND TISSUE EXTENSIBILITY, Robertson
Arch Phys Med Rehabil Vol 86, April 2005