OCT 016 (Occupational Therapy and
Musculoskeletal Rehabilitation- Laboratory)

STUDENT ACTIVITY SHEET BS OCCUPATIONAL THERAPY / THIRD YEAR

 
                                                  Session # 17
 

     
LESSON TITLE: PHYSICAL AGENT MODALITIES Materials: 
LEARNING OUTCOMES:  Book, pen, paper and notebook 
References:
Upon completion of this lesson, the OT student can:
● Pendleton, H. M., & Schultz-Krohn, W.
1. Identify the role of physical agent modalities in
(2018). Pedretti's occupational therapy:
occupational therapy practice.
Practice skills for physical dysfunction. St.
2. Describe the appropriate indications for use of
Louis, MO: Elsevier.
superficial thermal agents, deep thermal agents, and
● Radomski, M. V., & Latham, C. A. (2014).
electrotherapeutic agents.
Occupational Therapy for Physical
3. Describe how and why preparatory methods, such as
Dysfunction. Philadelphia: Lippincott Williams
PAMs, are used in occupational therapy practice.
& Wilkins.
4. List the precautions and contraindications in the use of
select physical agents.
5. Discuss the current evidence and its implications for
using physical agents as part of a comprehensive
occupational therapy treatment plan.

LESSON PREVIEW / REVIEW

The profession of occupational therapy has a long and colorful history, adapting and changing in response to internal and
external issues and challenges. The use of physical agent modalities in clinical practice has not always been embraced
within the occupational therapy professional community. However, when the new accreditation standards for occupational
therapy education programs went into effect in 2008, all entry-level occupational therapy and occupational therapy
assistant students were, for the first time, required to demonstrate some knowledge of physical agents upon graduation
(AOTA, 2007a, 2007b, 2007c). The implementation of this educational requirement symbolized the widespread
acceptance of using physical agents in occupational therapy practice. Physical agents are now an accepted tool for
preparing clients for occupational performance.

MAIN LESSON 
Physical agent modalities are interventions or procedures that produce a response in soft tissue through the use of light,
water, temperature, sound, electricity, or mechanical devices. They are applied to modify specific client factors and
prepare clients for engagement in occupations when neurological, musculoskeletal, or skin conditions limit occupational
performance. Physical agent modalities are used in preparation for or concurrently with purposeful and occupation-based
activities (American Occupational Therapy Association [AOTA], 2012). There are four primary classifications of physical
agents: superficial thermal agents, deep thermal agents, electrotherapeutic agents, and mechanical devices. Superficial
thermal agents include hydrotherapy/ whirlpool; cryotherapy; Fluidotherapy®; hot packs; and paraffin, water, and infrared
heating. Deep thermal agents include therapeutic ultrasound, phonophoresis, and short-wave diathermy.
Electrotherapeutic agents include biofeedback, neuromuscular electrical stimulation (NMES), functional electrical
stimulation (FES), transcutaneous electrical nerve stimulation (TENS), high-voltage galvanic stimulation (HVGS), high-

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voltage pulsed current, direct current, and iontophoresis. Mechanical devices may include vasopneumatic devices and
continuous passive motion devices (AOTA, 2012).

The overall purpose of occupational therapy is to support health and participation through engagement in occupation
(AOTA, 2008). Physical agent modalities are used as part of a comprehensive occupational therapy treatment plan as
preparatory interventions to facilitate outcomes in our clients as quickly and as cost effectively as possible. The focus is
always on helping our clients engage in their occupations. Physical agents can help increase soft tissue extensibility,
reduce pain and inflammation, and improve muscle performance to help clients more successfully engage in occupational
activity. Although other health professions may also use physical agents as part of their treatment, the occupational
therapy profession’s distinct approach always focuses on occupational performance.
Evidence-Based Practice, Physical Agent Modalities and Clinical Decision Making
In its Centennial Vision (AOTA, 2007d), the American Occupational Therapy Association has identified evidence-based
practice as a key component in linking education, research, and practice. It is imperative that we occupational therapists
substantiate the efficacy of our interventions to preserve the long-term viability of our profession. Our professional
literature has seen a rise in the number of research reports, including randomized controlled trials and systematic reviews,
over the past 10 years, but there is still much work to be done. Many interventions used in clinical practice still need to be
studied and validated. The use of physical agent modalities is one such area that requires more research. For the most
part, the evidence in peer-reviewed literature is contradictory when it comes to the efficacy of most physical agents. In the
absence of definitive external evidence, however, we must remember that the founders of the evidence-based medicine
movement never intended for high-level research to be the only evidence upon which we base clinical decision making.
Effective clinicians combine knowledge of the best published evidence with their own clinical skills and judgment, as well
as patient preference, to develop the most appropriate plan of care for each individual patient. Therefore, it is perfectly
acceptable, in the face of contradictory literature, for a clinician to use a physical agent to prepare a client to more
successfully participate in an occupation-based activity if, in the therapist’s experience or anecdotal knowledge, the agent
has been successful with another similar client. The therapist must carefully observe the client’s reaction. Improved
performance is evidence of treatment efficacy.
Incorporating Physical Agents into A Typical Occupational Therapy Treatment
Physical agents are used as a precursor to, or during, functional activity to facilitate occupational performance. The
therapist determines which physical agents will help achieve the patient’s goals. Physical agents address pain and other
biophysiological client factors that interfere with engagement in occupation. For example, a patient with osteoarthritis of
the hand may have joint pain. Any physical agent that relieves the pain of hand osteoarthritis may help improve function
(Barthel et al., 2010). Therapeutic ultrasound, for example, has been shown to have beneficial effects on pain and
functional outcomes in patients with osteoarthritis (Srbely, 2008). An occupational therapist might use ultrasound to
alleviate the patient’s hand pain prior to training with adaptive equipment for self-care activities. Patients with lateral
epicondylitis report pain at the elbow that interferes with grip strength and function. The cause of this condition is
degeneration of the common extensor tendon fibers where they originate on the lateral epicondyle, and it is closely
associated with overuse and inflammation. A number of studies support using a specialized type of electrical stimulation—
called iontophoresis—to reduce pain and thus improve grip strength and function in patients with lateral epicondylitis
(Nirschl et al., 2003; Stefanou et al., 2012).

Iontophoresis uses electrical charges to drive medication through the skin and into the body. Occupational therapists
might use iontophoresis to deliver anti-inflammatory medication to chronically inflamed tissues in the elbow to reduce pain
and promote healing in preparation for return to work activity. Before administering any modality, the therapist should
question the patient about any negative response to physical agents applied in previous treatment and review whether the
patient has any contraindications for the selected agent. Prior to administering the physical agent, the therapist should
inform the patient as to the procedure, expected outcome, and subjective sensation that the patient may feel during the
treatment. Skin integrity should always be evaluated prior to administration of physical agents and immediately following
the intervention. Documentation should be clear and concise. Therapists should also assess the effectiveness of the
modality on a session-by-session basis. If the modality fails to provide the desired outcome or if the patient has discomfort
or negative results, the modality should be discontinued.

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THERMOTHERAPY
Thermotherapy is the term used to describe the therapeutic application of heat. A thermotherapy agent is any modality
applied to the body that increases tissue temperature. These agents are further classified as either superficial-heating
agents or deep-heating agents. Superficial agents heat tissues at depths of up to 1 cm (Kaul, 1994). Commonly used
superficial-heating agents include warm whirlpool baths, Fluidotherapy®, hot packs, and paraffin. Deep-heating agents
heat tissues at depths up to 5 cm. Therapeutic ultrasound is commonly used to deliver deep heat.

The four primary biophysiological effects of thermotherapy are analgesic, vascular, metabolic, and connective tissue
responses.
● The analgesic effect reduces pain symptoms. Heat acts selectively on free nerve endings, tissues, and peripheral nerve
fibers, which directly or indirectly reduces pain, elevates pain tolerance, and promotes relaxation.
● Vascular effects aid in pain relief and in decreasing muscle spasm and spasticity. As the temperature of tissue elevates,
substances such as histamines are released into the bloodstream, resulting in vasodilation. This increased blood flow
reduces ischemia, muscle spindle activity, tonic muscle contractions, spasticity, and pain.
● Metabolic effects influence tissue repair and aid pain relief. In addition to the vascular effect of increased circulation,
thermal agents affect inflammation and healing because of chemical reactions. Increases in blood flow and oxygen within
the tissues bring a greater number of antibodies, leukocytes, nutrients, and enzymes to injured tissues. Pain is reduced by
the removal of by-products of the inflammatory process. Nutrition is enhanced at the cellular level, and repair occurs.
● The connective tissue response to heat refers to the fact that biological tissues are more easily stretched after heating.
Collagen is the primary component protein of skin, tendon, bone cartilage, and connective tissue. Those tissues
containing collagen can become shortened because of immobilization or limited range of motion (ROM) as a result of
weakness, injury, or pain. Improvement in the properties of collagen and extensibility of tissues occurs when heat is
combined with passive or active mobilization and/or engagement in occupation. This ultimately results in reduced joint
stiffness and increased ROM.

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Common Superficial Heating Modalities in the Occupational Therapy Clinic
Whirlpool Baths
Whirlpool treatment is performed in a tank equipped with a water circulating mechanism that draws water out and pushes
it into the tank at varying speeds (whirlpool bath). Water temperature is usually set between 99°F and 104°F (37.2°C–
40°C) and should never exceed 110°F (43.3°C). Treatment time is approximately 20 minutes. Advantages of whirlpool use
are that the client can actively exercise the extremity as the tissue heats up, the therapist has easy access to the
extremity for providing active-assistive and passive mobilization, and the degree of agitation of the water can be controlled
to act as a soft tissue massage or resistance for exercise.
Safety Message: However, the use of whirlpool is contraindicated when significant edema is present. The heat as well as
the unavoidable and prolonged dependent position of the extremity in the whirlpool bath almost always increases edema.
Additionally, whirlpool is contra-indicated when open wounds are present. Cross- contamination and risk for infection is
significant because it is difficult to adequately disinfect all parts of the whirlpool bath between patients.
Fluidotherapy®
Fluidotherapy® uses fi ne particles of organic cellulose blown around in a hot air stream inside a containing unit to heat an
extremity. The force of the air and particles circulating within the machine can be graded via the blower speed. It is like a
dry whirlpool bath. Temperature is controlled by a thermostat and is generally set between 105°F and 118°F (40.5°C–
47.7°C). Treatment time is approximately 20 minutes. The advantage of Fluidotherapy® is the ease of implementation, the
client can actively exercise the extremity as the tissue heats up, the therapist has easy access to the extremity for
providing active-assistive and passive mobilization, and the dry cellulose particles can provide desensitization therapy
during the heating process.
Safety Message: Extremities with open wounds should not be placed in the Fluidotherapy® machine and all clients
should wash the area to be treated with soap and water prior to using this modality.
Hot Packs
Hot packs are canvas cases of material stored in a thermostatically controlled container of hot water called a
hydrocollator. Water temperature is kept at approximately 165°F (73.8°C). When the pack is removed from the water, its
temperature is typically between 104°F and 113°F (40°C–45°C). The pack is then wrapped in dry padding with
appropriate towel use and applied to the body to provide moist heat. Treatment time is approximately 20 minutes. The
advantages to hot packs are that they are simple to use, are widely available, and can heat large surface areas.
Disadvantages include the heaviness of hot packs—which can be uncomfortable for the patient—as well as their difficulty
in conforming to small multisurface body parts such as the hand. Another disadvantage to hot packs is that the area being

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treated must be nonmobile and covered. This limits active and active- assistive mobilization during the heating process,
although a joint can be placed on passive stretch while being heated with a hot pack. The therapist should also remember
to rotate the hot packs inside the hydrocollator because packs cool during use. It takes approximately 30 minutes to
adequately reheat a hot pack to a therapeutic temperature between uses.
Safety Message: It is important to ensure that six to eight layers of dry padding is used between the hot pack and the
skin to avoid burns. Toweling is commonly used to cover hot packs. Commercially available terry cloth “hot pack covers”
are also available and are the equivalent of three to four layers of toweling. If toweling and hot pack covers become damp
from repeated use throughout the day, more heat is transferred from the hot pack to the body. Therefore, padding should
be rotated and allowed to dry, or more layers of moist padding will be needed to avoid tissue burns.
Paraffin
Therapeutic paraffin baths consist of a thermostatically controlled heating unit filled with a commercial mixture of paraffin
wax and mineral oil. Mineral oil is used to lower the melting point of the paraffin. Paraffin baths are kept at temperatures
between 120°F and 130°F ( 48.8°C–54.4°C). Paraffin is often the heating agent of choice for occupational therapists
working with hand dysfunction. This is because paraffin easily conforms to the contours of the hand and therefore
provides even distribution of heat to all surfaces. The patient immerses the hand in the bath for 1–2 seconds and
withdraws it to allow the paraffin to harden. This gloving process is repeated 8–10 times, and then the hand is wrapped in
a plastic bag followed by a towel to retain the heat. The paraffin, bag, and towel are left on for 20 minutes. At the end of
treatment, the paraffin is removed and discarded. A disadvantage to this form of paraffin treatment is that the hand needs
to remain still during the heating process, and this limits active and active-assistive mobilization.
Safety Message: The therapist should always check the temperature of the paraffin before each use to ensure a safe
temperature and avoid burns. Paraffin is not appropriate to use when open wounds are present at the treatment site, and
the client should wash the entire extremity with soap and water before using the paraffin bath.

CRYOTHERAPY
Cryotherapy–also called “cold therapy”—is the therapeutic application of physical agents to lower tissue temperatures.
Cryotherapy is classified as a superficial thermal agent because it moves heat out of the body. Cold therapy agents can
affect tissue temperatures to a depth of 2 cm (Bracciano, 2008). Commonly used cooling agents include commercial and
homemade ice packs and ice massage. The primary biophysiological effects of cryotherapy are analgesic, vascular,
metabolic, and neuromuscular.
● The analgesic effect influences pain symptoms. Cold elevates the pain threshold through counterirritation and by
reducing nerve conduction velocity in the more superficial sensory nerves (Algafl y & George, 2007; Herrera et al., 2010).
● Vascular effects include both vasoconstriction (when cold is applied for less than 15 minutes) and vasodilation (when
cold is applied for longer than 15 minutes) (Bracciano, 2008). Short-term application of cold therapy can help reduce
edema.
● Metabolic effects influence inflammation and tissue repair. Application of cold therapy slows down the metabolic
processes of tissue repair and should therefore be used thoughtfully. We do not want to interfere with the normal healing
process, but cold therapy can be useful to control excessive inflammation and edema in the very early stages of healing.
● Neuromuscular effects influence muscle tone. Cold therapy can temporarily reduce spasticity in patients with upper
motor neuron lesions (dos Santos & de Oliveira, 2004).

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Common Cooling Modalities in the Occupational Therapy Clinic
Cold Packs
Cold packs come in a variety of shapes and sizes. They are commercially available as cold therapy machines and gel
packs, or they can be homemade. Cold therapy machines circulate cold water through an insulated cooler and special
sleeve that covers the body part. Commercial gel packs are generally made from gel covered with a type of plastic. They
can be kept in a standard household or industrial freezer between uses. Cold packs can also be made from crushed ice
wrapped in toweling or placed in a plastic bag. An unopened bag of frozen peas can serve as a cold pack and works well
to conform to small rounded areas like the hand. Cold packs can also be made by combining three parts water to one part
isopropyl alcohol in a plastic zip-seal bag and freezing. The alcohol will keep the mixture from fully freezing, resulting in a
slushy soft cold pack similar in consistency to some commercial gel packs. Cold packs should always be covered with a
material such as toweling or a pillow case. A dry covering will make the initial contact with the patient more comfortable
and slow the cooling process. Wetted cold pack covers cause more rapid cooling of tissues. Treatment time can be up to
20 minutes, but the patient should be monitored for signs of cold intolerance or tissue damage. The advantages of cold
packs are that they are inexpensive, are easy to find or make, and can cover large areas. A disadvantage of some cold
packs is that they can be difficult to conform to smaller, multi-surface areas such as the hand.
Ice Massage
Ice massage requires holding ice directly against the skin and moving it in slow circles over the target tissue. This
technique is normally used for cooling small areas such as tendon insertion sites and hyper-irritable muscle spots to
produce an analgesic effect. Because tissues are cooled so rapidly during ice massage, this treatment generally takes no
longer than 10 minutes, and treatment time should be guided by how the patient feels. The patient can expect to
experience the sensation of cold, then burning, then aching, and finally numbness. Once the patient experiences
numbness, the ice massage should be discontinued. It can become uncomfortable for the therapist to hold a piece of ice
in his or her bare hands for the duration of the treatment, so ice cubes can be held with a folded wash cloth. Alternatively,
small Styrofoam or paper cups can be filled with water and frozen. Prior to starting an ice massage, the top rim of the cup
is peeled off to expose the ice tip. The therapist then holds the cup part while performing the massage. This protects the
therapist’s hands from the ice. As the ice melts during the massage, more cup can be peeled away to expose more ice.
Advantages to ice massage include ease of use, little expense, and quick inducement of analgesia in appropriate tissues.
A disadvantage to ice massage is that it is not tolerated well by people who do not want to endure the sensations of
burning and aching prior to reaching the stage of numbness. Additionally, ice massage can be messy as the ice melts, so
protect your patients’ clothing with dry toweling during this procedure.
THERAPEUTIC ULTRASOUND
Ultrasound is acoustic energy (sound waves) used in medicine for diagnosis and in rehabilitation to help restore and heal
soft tissues. Therapeutic ultrasound is classified as a deep-heat modality. Ultrasound is inaudible high frequency acoustic
vibration that produces thermal and/or nonthermal (mechanical) physiologic effects on tissue. Thermal effects refer to
those biophysiological changes produced by cellular heating, whereas nonthermal, or mechanical effects, refer to
biophysiological changes produced by the cellular effects of cavitation, microstreaming, or acoustic streaming. Both
thermal and nonthermal ultrasound can be used to facilitate healing and ultimately improve occupational function.

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Physical Principles
Standard ultrasound units consist of a power supply, generator, coaxial cable, transducer, and crystal. The generator
produces a high frequency alternating current at 1–3 million cycles per second (MHz). The alternating current travels
through the coaxial cable into the transducer. The transducer houses the vibrating crystal and converts electrical energy
into ultrasonic or acoustic energy. The vibration of the crystal generates the sound waves, which are transmitted to a
small volume of tissue, causing molecules within the tissue to move. Ultrasound travels poorly through air, so a lubricant
is used to maintain contact between the transducer and the tissue, ensuring that the energy is dispersed into the tissue
(Draper, 2010). When the sound waves are generated rapidly and dispersed into the tissue, the molecules in the waves’
path are pushed back and forth by the alternating phases of successive waves until the wave runs out of energy. This
type of wave, moving in one direction and compressing and decompressing the molecules in its way, is termed a
longitudinal wave.

When the wave encounters bone, the sound energy is transferred along the periosteum and is then deflected up at a right
angle causing a shear wave. Shear waves occur when the sound energy strikes a solid substance. This may cause
heating of the outer covering of the bone but is negligible in terms of tissue temperature elevation (Bracciano, 2008;
Cameron, 2012). A standing wave occurs when the sound head is not moved adequately enough, and the incoming
sound waves encounter the reflected sound waves moving back up toward the surface, creating hot spots and potential
overheating of tissue. Each tissue in the body transmits and absorbs ultrasound energy according to its unique properties,
known as absorption coefficients. The rate at which the sound wave travels depends on the density of the molecules of
the tissue, with body fluids such as blood and water having the lowest impedance and lowest acoustic absorption
coefficient. Bone, along with other protein-dense structures, such as scars, joint capsules, ligaments, and tendons,
possess high impedance and absorption coefficients, making them good absorbers of ultrasound energy (Kimura et al.,
1998).

Effects on Tissue: Thermal Versus Nonthermal Ultrasound

In the thermal mode, ultrasound is a deep-heating agent capable of elevating tissue temperatures to a depth of 5 cm.
Thermal effects are typically achieved with continuous sound waves (as in a 100% duty cycle). Nonthermal ultrasound
exerts mechanical effects at the cellular level such as increased cellular permeability and diffusion but does not elevate
tissue temperature. It typically involves delivering the ultrasound at a 20% duty cycle (on 20%, off 80% of each cycle).
Clinicians may use ultrasound to achieve thermal or nonthermal effects and must select the effect considering a patient’s
given problem and the therapeutic effect that is desired.

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Phonophoresis
Phonophoresis is the use of ultrasound to facilitate the delivery of topically applied drugs or medication to selected tissue.
Although it is used by some practitioners, there are questions as to its effectiveness because of variability in outcomes
associated with inconsistent treatment parameters, such as intensity of sound waves and transmission characteristics of
the conducting medium (typically hydrocortisone cream or a dexamethasone sodium phosphate sonic gel mixture).
Therapists should review current literature prior to selecting phonophoresis as the treatment modality of choice.
Precautions for Use of Ultrasound
Patients should be monitored during ultrasound, and any pain or discomfort may indicate that the intensity is too high or
that there is an inadequate amount of gel. When using ultrasound as a thermal agent, one must follow general
contraindications and precautions for any thermal modality.

ELECTROTHERAPY
The growth of the use of electrical stimulation in recent years is due to advances in technology. Electrical stimulation is
used in the clinical setting to increase muscle strength, decrease muscle spasm, decrease swelling, improve tissue
healing, decrease pain, and provide an option for longer lasting analgesia. Frequently used applications include NMES,
TENS, electrical stimulation for tissue repair (ESTR), FES, electrical muscle stimulation (EMS), interferential current
therapy (IFC), and iontophoresis. Surface electromyography biofeedback monitors the level of electrical activity in

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muscles (helps determine how well somebody is able to recruit muscle activity on their own) and is often paired with
NMES.
● NMES uses pulsating, alternating current to activate muscles through stimulation of intact peripheral nerves to cause a
motor response. Stimulation of the nerve is used to decrease muscle spasm, to strengthen muscle, and to cause muscle
pumping that can reduce edema. NMES stimulation applied directly to innervated muscle is used for muscle reeducation
and to prevent atrophy.
● FES is electrical stimulation used to activate targeted muscle groups for orthotic substitution or to facilitate performance
of functional activities or movements. FES is often used with individuals who have shoulder subluxation or foot drop after
a stroke.
● TENS operates on the gate theory and describes the wide variety of stimulators used for pain control. TENS uses
surface electrodes placed strategically over regions of pain to stimulate specific afferent nerve fibers with the goal of
sensory analgesia rather than a motor response.
● EMS is electrical stimulation of denervated muscle to facilitate viability and to prevent atrophy, degeneration, and
fibrosis of the fibers. EMS facilitates nerve regeneration and muscle reinnervation.
● IFC utilizes two channels (four electrodes placed in a vector pattern) simultaneously with different frequencies. This
allows for a more comfortable surface and deeper tissue penetration to help with pain reduction and edema management.
● Iontophoresis is the use of low-voltage direct current to ionize topically applied medication into the tissue. Iontophoresis
is often used in the treatment of inflammatory conditions or for scar formation and management.
● ESTR, also known as high-voltage galvanic stimulation, has been used for tissue healing.
Treatment Planning Specific to Electrotherapy
Before incorporating electrotherapy into treatment, clinicians make decisions about the type of electrical stimulator to use
and placement and size of electrodes.
Parameters of Electrical Stimulation Devices
Because research has been equivocal, the clinician must critically evaluate the claims made for various outcomes of
electrotherapeutic interventions. Prior to use, the therapist should be familiar with the specific capabilities of the available
stimulators and their stimulation parameters (types of current offered, frequencies, intensities, treatment guidelines, etc.).
Electrodes
Electrodes are the contact point providing the current flow from the stimulation device to the body. The electrode
interfaces with the skin surface at the point where the electron–ion conversion occurs. Electrodes should offer little
resistance to the current flow. A variety of electrodes are commercially available. Commonly used electrodes include
carbon-rubber electrodes, which are silicon rubber impregnated with small carbon particles; metal- or foil-backed
electrodes; sponges over metal plates; and self-adherent polymer electrodes (Draper, 2010). The self-adhering electrodes
may be reusable and do not require strapping or taping, making them convenient to use. Full contact with the skin is
crucial, which is facilitated by use of electrode gel. Electrodes should be examined before each use and changed when
necessary. Electrodes degrade with use and become unable to conduct the current efficiently.

Therapists should look for cracking and worn spots in the carbon-rubber electrodes or excessive dryness in self-adhering
electrodes and replace them as needed. With frequent use, carbon-rubber electrodes may develop nonconductive areas
because of the absorption of dirt, skin oil, or electrode gel and depletion of the carbon rubber. This may cause “hot spots,”
areas of high current density that may be uncomfortable for the patient and cause skin burns. When uneven conductivity
causes a biting or stinging sensation during electrical stimulation, the electrodes should be replaced. Regardless of the
type of electrode used, it is necessary to prevent skin irritation or breakdown. This factor becomes critically important for
patients who are using the stimulators on a home program or when there is prolonged placement and use of the
electrodes.

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Neuromuscular Electrical Stimulation
NMES has a variety of clinical uses as an adjunct to occupational therapy treatment. NMES is the electrical stimulation of
an intact or partially intact peripheral nerve to evoke a muscle contraction (Bracciano, 2008). NMES is often erroneously
referred to as “functional” electrical stimulation. Functional electrical stimulation, or FES, is a subcategory of NMES and
refers to the use of NMES as a substitute for an orthosis to assist with a functional activity, such as standing or holding an
object, or as a substitute for a sling. NMES can be used for strengthening and endurance, ROM, facilitation of muscle
function, management of muscle spasms and spasticity, edema reduction, and orthotic substitution (Cahe, Yu, & Walker,
2004). Clinical use of NMES requires a partially intact or intact peripheral nerve, and its use with primary muscle disease
or muscular dystrophy is unwarranted.
Functional Electrical Stimulation
FES, the use of NMES as a replacement for orthoses, has been an effective adjunct in facilitating occupational function,
most notably positional stability and mobility. Stimulation of innervated paretic or paralyzed muscles can decrease
dependence on slings, splints, or other orthoses through the development of increased strength and endurance of the
paretic musculature. FES has been effectively used with hemiparetic patients who display shoulder subluxation during the
flaccid phase of recovery and also to facilitate grasp and release activities (Thrasher et al., 2008). In the hemiplegic
patient, gravity stresses the shoulder capsule, stretching it. When muscle tone and voluntary control develop at the
shoulder, normal glenohumeral alignment may not recur when the arm is at rest because of this ligamentous laxity (Yu et
al., 2001). Slings may be helpful to establish glenohumeral alignment, but stimulation of the posterior deltoid and
supraspinatus muscles may be more effective in improving normal shoulder integrity (Koyuncu et al., 2010; Lin, Granat, &
Lees, 1999; Wang, Chan, & Tsai, 2000). Use of FES for maintaining shoulder integrity can be an effective adjunct to
splinting and facilitate occupational function. Clearly outlining and teaching the client and caregivers in a home program is
vital to ensure continuity and carryover.
Transcutaneous Electrical Nerve Stimulation
Pain is one of the most common complaints that cause patients to seek medical care. Adequate pain management
facilitates
occupational function. TENS can be used to manage pain in musculoskeletal disorders. The two primary theories on
which the modulation of pain with TENS is based are the gate control theory (Melzack & Wall, 1965; Robertson et al.,
2006) and the endorphin theory (Bonica, 1990). Basically described, the gate theory is the stimulation of afferent nerves to
block pain by closing the gate in the spinal column to pain signals coming from slower conducting nerves. The endorphin
theory specifies that natural bet endorphins are released with the application of intense beat frequency of TENS that
inhibits pain signal transmission and decreases chemical irritants in the central nervous system (Draper, 2010).

Treatment applications using electrical stimulation for pain control employ pulsed or alternating current in a variety of
stimulation patterns. The type of stimulation is based on the neurological response to the stimulation with the goal being
pain relief and comfort. The four levels of stimulation used include subsensory level, sensory level, motor level, and
noxious level. Stimulation sites for electrode placement are based on the problem areas. Optimal electrode placements

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should correlate with the structures and sources of pain and include motor points, trigger points, and acupuncture points.
TENS units are often used at home, and the therapist should explain the purpose of the equipment and instruct the patient
in its operations and precautions, with written and pictorial instructions. Through application of TENS for sensory
analgesia, the patient may better perform functional activities and movements that foster independence and function
because they are in less pain.

Iontophoresis
Iontophoresis is a method of topically delivering a medication or ionized drug to an area of tissue by using direct electrical
current. Occupational therapists frequently use iontophoresis in the treatment of inflammatory conditions such as
epicondylitis, carpal tunnel syndrome, glenohumeral bursitis, ulnar nerve inflammation, and wrist tendinitis and
tenosynovitis. Therapists using iontophoresis should thoroughly understand the pathophysiology of the condition, the
tissue healing process, the medications being used, and any potential drug interactions. Documented orders should
always be obtained from the patient’s physician prior to using iontophoresis (Bracciano, 2008).
Safety Message: Caution must be used whenever using iontophoresis because medications may cause an allergic or
anaphylactic reaction, which is a life-threatening condition and medical emergency. Patients should always be asked for a
list of current medications and whether they have any known allergies, sensitivities, or reactions to foods or medications

CHECK FOR UNDERSTANDING

INSTRUCTIONS: In your lecture activity you already have chosen a physical agent modality that is applicable to your
client’s case. This time, for each case I want you to explain how this PAMS is administered, its indications and
contraindications.
CASE
A 52-year old certified nursing assistant has a diagnosis of adhesive capsulitis and frozen shoulder after a fall 3 months
ago. She works full-time and cares for elderly mother at home.
Occupational Goals: The client’s desired occupation is to continue to work and care for her mother in the home.
PAMS PROCEDURE INDICATIONS CONTRAINDICATIONS

The application of intense heat Ultrasound therapy is A contraindication is a

in addition to ultrasound for the
Ultrasound deep treatment of a patient's is
heat therapy referred to as a thermal state.
Warmth transported to the more
substantial levels of the tissue
will promote healing when that
grade. Achieving the main
goal ultrasound thermal
therapy is to reduce suffering
caused by soft tissue harm,
advised for conditions medical condition for
which using heat as a
that are alleviated by the kind of therapy is not
application of deep heat, advised. It might result in
harm and damage, and if
such as discomfort, things are already bad, it
muscular spasms, and might make them more
badly. The following
Joint contractures.
situations should not be
Specifically, these

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 including Sprains and stretches.
The therapist will finish first the
procedure by utilizing the
resources that are required,
such as gel and assistance.
The transducer's head is then
turned over and back and
forth which part of the body
has being hurt. The seriousness
of the penetration may be
modified based on how well
the afflicted region is reacting
to treatment.
Third, the course of treatment is
brief longer than ten minutes in
total, administered a maximum
of once each day.
conditions include, The
use of therapeutic
ultrasound is effective in
treating a wide variety of
injuries and illnesses,
including
bursitis/capsulitis,
epicondylitis, ligament
sprains, tendinitis, scar
tissue repair, and
muscular strains that
have persisted for a
lengthy period of time.
treated with heat:
Alterations to your
senses could cause you
to lose the ability to
perceive pain, touch, or
temperature. You will not
be able to detect whether
your heat pack is too hot.
Burns, hyperthermia, and
similar heat-related
injuries should not be
treated. Sensitive to heat
or cold to extremes. Here,
you feel the effects of
heat more acutely (or
less acutely),
respectively. Issues with
blood flow

A 26-year old computer engineer presents with severe pain in her dominant UE after a fall 4 months ago where she
sustained an elbow fracture and wrist sprain. She has 9/10 pain with all grasping, lifting, and carrying and has a diagnosis
of CRPS. She has limited grip strength and therefore limited function. She works full-time and has a 1-year old child at
home. She is having difficulty with activities involving lifting, carrying, child care, and meal preparation and reports that
she has increased pain while typing on the computer for her work-related tasks.
Occupational Goals: The client would like to be able to better manage her pain and she resumes her usual occupations
in the home and work setting.

PAMS PROCEDURE INDICATIONS CONTRAINDICATIONS

1. Wash your hands with soap those who have the Paraffin baths are
and water and dry them. contraindicated for
Therapeutic following: individuals who have any
paraffin baths of the following:
1. Rheumatoid joints
2. Rub lotion onto your hands: 1. Open wounds in
Hand lotion allows the wax to be 2. Fibrositis
the treatment
removed easily after treatment. 3. Contrusion area.
2. Allergies to
4. Swelling
paraffin.
3. Dip your hand into the wax: 5. Strains 3. Impaired
Your fingertips should go in first. sensation in the
Keep your fingers separated and treatment area.
submerse your hand all the way
past the wrist if desired.

4. Remove your hand after it has

been coated with wax.

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 5. Repeat steps 3 and 4: Dip your
hand 6-8 times, waiting a few
seconds between each dip. This
allows layers of wax to form over
your hand.

6. Immediately cover your hand

with a plastic bag and wrap with
a hand towel: Wait 10-15
minutes. This will create moist,
deep heat for your hand.

7. Remove the towel, plastic bag

and cooled wax after 10-15
minutes.

8. Return the wax from your

hand to the paraffin unit for
reuse.

9. Proceed with exercises that

have been recommended by
your hand surgeon and/or hand
therapist.

RATIONALIZATION ACTIVITY 

IMPORTANT REMINDER: As an Occupational Therapist, I understand that we all have a unique and different
perspective or ways in dealing with our client may it be in assessing or giving interventions to them. As a result, please
take note that in this part of the session I will only provide you with guidelines that you need to consider when answering
the questions above.

Please refer to the rubric below as your guide in answering the questions.

GRADE RUBRIC FOR OUTPUTS

Criteria Inadequate (Below Adequate (Meets Above Average Exemplary (Far Exceeds
Standard) Standard) (Exceeds Standard) Standard)

5% 7.5% 8.5% 10%

Organization Writing lacks logical Writing is coherent and Writing is coherent and Writing shows high degree

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 organization. It logically organized. logically organized with of attention to logic and
shows some Some points remain transitions used reasoning of points. Unity
coherence but ideas misplaced and stray between ideas and clearly leads the reader to
lack unity. Serious from the topic. paragraphs to create the conclusion and stirs
errors. Transitions evident but coherence. Overall unity thought regarding the topic.
not used throughout of ideas is present.
essay.

Level of Shows some thinking Content indicates Content indicates Content indicates synthesis
Content and reasoning but thinking and reasoning original thinking and of ideas, in-depth analysis
most ideas are applied with original develops ideas with and evidences original
underdeveloped and thought on a few sufficient and firm thought and support for the
unoriginal. ideas. evidence. topic.

Development Main points lack Main points are Main points well Main points well developed
detailed present with limited developed with quality with high quality and
development. Ideas detail and supporting details and quantity support. Reveals
are vague with little development. Some quantity. Critical thinking high degree of critical
evidence of critical critical thinking is is weaved into points thinking.
thinking. present.

Details and No use of specific Little use of specific Some use of specific Large amounts of specific
Examples examples; mostly examples and details; examples and detailed examples and detailed
generalized and with mostly generalized descriptions. May have descriptions.
little detailed examples and little extended examples that
description. description. go on for too long

Grammar and Spelling, Most spelling, Essay has few spelling, Essay is free of distracting
Mechanics punctuation, and punctuation, and punctuation, and spelling, punctuation, and
grammatical errors grammar correct grammatical errors grammatical errors; absent
create distraction, allowing reader to allowing reader to follow of fragments, comma
making reading progress though ideas clearly. Very few splices, and run-ons.
difficult; fragments, essay. Some errors fragments or run-ons.
comma splices, run- remain.
ons evident. Errors
are frequent.

LESSON WRAP-UP

In which part of this session did you have the most difficulty in dealing with?

For me, it was getting a hold of the idea of all methods shown.

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How were you able to overcome the difficulties that you have encountered in this session?

I researched the methods that were unclear to me

You are done with the session! Let’s track your progress. Please encircle the current session that you have finished.

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