REVIEWER IN PHYSICAL AGENTS ▪ 3 – 6 months

▪ More than 4 days (clinic)

AND ELECTROTHERAPY o Pain that has responded inadequately to
appropriate and/or invasive care
PAIN AND INFLAMMATION
o Pain associated with significant and
PHASES OF INFLAMMATION AND HEALING reliable impairment of functional status
➢ NEUROPATHIC PAIN
PHASE 1: INFLAMMATORY PHASE • Direct consequence of a lesion or disease
➢ Duration: Days 1 – 6 / < 4 days affecting nerves
➢ Prepares the wound for healing • Radicular Pain – coming from neck or low back
➢ Begins when the normal physiology of tissue is pain (spinal)
altered by disease or trauma ➢ DYSFUNCTIONAL PAIN
• To destroy pathogens at fault • Signs: persistent, spreading, worsening pain,
• Limit bleeding pain with small movements, unpredictable pain,
pain without an identifiable cause
CARDINAL SIGNS OF INFLAMMATION o Pagod na di alam kung baket
➢ PSYCHOGENIC PAIN
➢ Calor – heat
• Pain wherein psychological processes play a
➢ Rubor – redness
large role
➢ Tumor – swelling
o Feelings, emotions
➢ Dolor – pain
➢ Function laesa – loss of function ATTRIBUTES OF PAIN
PHASE 2: PROLIFERATION PHASE ➢ Location
➢ Quality
➢ “Proliferative Phase”
➢ Quantity or severity
➢ Duration: Day 3 – Day 20
➢ Timing (onset, duration, frequency)
➢ Collagen is deposited in the damaged area to replace
➢ Setting in which it occurs
the destroyed tissue
➢ Aggravating and relieving factors
• To control scar formation ➢ Associated manifestations
• Fibroblasts – cover wound
• Keloid – lampas sa scar PAIN DESCRIPTIONS AND RELATED
• Hypertrophic Keloid – lumolobo within the STRUCTURES
boundaries of the scar TYPES OF PAIN STRUCTURE
Cramping, dull, aching Muscle
PHASE 3: MATURATION PHASE Dull, aching Ligament, joint capsule
Sharp, shooting Nerve root
➢ Duration: Day 9 – 2 years (longest phase) Sharp, bright, lightning- Nerve
➢ Organization of the collagen tissue into a more like
definitive pattern Bruning, pressure-like, Sympathetic nerve
• Good tensile strength stinging, aching
Deep, nagging, dull Bone
PAIN Sharp, severe, intolerable Fracture
Throbbing, diffuse Vasculature
➢ Is an unpleasant sensory and emotional
experience associated with, or resembling that
associated with, actual or potential tissue damage. PAIN INTENSITY
(International Association for the Study of Pain, 2020)
➢ Verbal Rating Scale / Verbal Report Scale (VRS)
TYPES OF PAIN ➢ Visual Analogue Scale (VAS)

➢ ACUTE PAIN
• Occurs as a direct result of actual or potential
tissue injury due to a wound, a disease process,
or an invasive procedure
➢ CHRONIC PAIN
• Criteria:
o Enduring or recurrent pain
o Pain persisting longer than is typical for
an associated condition
 PHYSICAL AGENTS
Maintain/increase ES,
➢ Include heat, cold, water, pressure, sound, muscle strength hydrotherapy
electromagnetic radiation, and electric currents and flexibility (w/ exercise)
➢ Physical modality, physical agent modality,
electrophysical agent modality Control scar Compression
formation garment, elastic
CATEGORIES OF PHYSICAL AGENTS bandage
Maturation Maintain/increase ES,
THERMAL AGENTS
Phase muscle strength hydrotherapy
➢ Increase or decrease tissue temperature (w/ exercise)
➢ Examples: hot packs, ice packs, ultrasound,
Control scar
Compression
whirlpool, diathermy, IR lamp
formation garment, elastic
• Thermotherapy – heat bandage
• Cryotherapy – cold PHYSICAL AGENTS FOR PAIN MODULATION
• Diathermy – emit heat and electric GOAL OF THE WHAT TO USE
• IR Lamp – emit heat and electric INTERVENTION
• Ultrasound – produced heat because of sound Acute Pain Control pain, Cryotherapy,
prevent TENS, elastic
MECHANICAL AGENTS aggravation of bandage
pain
➢ Increase or decrease pressure on body Chronic Pain Control pain Thermotherapy,
➢ Examples: water, traction, compression, ultrasound TENS
• Hydrotherapy – water
Promote function
ES,
ELECTROMAGNETIC AGENTS hydrotherapy
(w/ exercise)
➢ Electromagnetic radiation, electric currents
PHYSICAL AGENTS FOR RESTRCITED MOTIONS
➢ Examples: UV lamp, IR lamp, LASER (Light GOAL FO THE WHAT TO USE
Amplification by Stimulated Emission of Radiation), INTERVENTION
diathermy, electrical stimulator (ES), transcutaneous LOM due to Improve muscle ES,
electrical stimulator (TES/TENS) muscle activation and hydrotherapy
weakness strength (w/ exercise)
EFFECTS OF PHYSICAL AGENTS LOM due to Control pain Pain at rest & w/
➢ Modification of tissue inflammation pain motion: TENS,
cryotherapy
➢ Pain relief
(acute),
➢ Alteration of collagen extensibility
thermotherapy
➢ Alteration of muscle tone

PHYSICAL AGENTS FOR TISSUE HEALING Relieve nerve Pain & motion
GOAL OF THE WHAT TO USE compression restriction due
INTERVENTION to spinal
Acute Prevent further Cryotherapy compression:
Inflammation swelling or with elastic spinal traction
bleeding bandage or LOM due to Increase soft Thermotherapy
compression soft tissue tissue (deep)
garment shortening extensibility,
decrease muscle
Control pain Cryotherapy, spasm
TENS
GENERAL CONTRAINDICATIONS AND
Limit motion Elastic bandage
PRECAUTIONS
Chronic Increase Thermotherapy,
Inflammation circulation TENS ➢ Contraindications (bawal) vs Precautions (can be
applied but with care)
Manage pain
• Pregnancy
Decrease joint • Malignancy (cancer)
stiffness • Pacemaker/other implanted electronic device
Proliferative Promote Thermotherapy • Impaired sensation
Phase circulation • Impaired mentation
 EXALUATION AND PLANNING FOR THE USE OF
PHYSICAL AGENTS
1. Identify the patient’s problem and goal of
intervention
2. Identify the physical agents that can be used to
treat the patient’s problem
3. Identify contraindications, precautions
4. Evidence for physical agent use, *patient’s
preference
5. Availability, convenience
SAMPLE CASES
1. JK, a 65-year-old female diagnosed with
osteoarthritis on (B) knee 8 months ago, c/o dull,
aching pain (VRS 6/10) on medial aspect of (B)
knees. The patient reported difficulty performing
household chores due to knee pain.
• Problem: chronic pain
• Goal: control pain, promote function
• What to Use: thermotherapy, TENS, ES,
hydrotherapy (w/ exercise)
2. XR is a 45-year-olf male who complains of neck pain
for more than 4 weeks. Recently, he reported that he
experienced intense sharp, shooting, pinch-like pain
(VRS 8/10) on his (L) neck after closing his car door.
After this incident, he reported that the pain (VRS
5/10) is radiating distally to his (L) arm up to his thumb
and index finger with his symptoms increasing over
the course of the day. He also stated that the pain in
the (L) arm is accompanied by numbness.
• Problem: radicular pain
• Goal: relieve neck compression
• What to Use: spinal traction
3. MO, a 20-year-old male reports dull, aching pain
(VRS 10/10) on lateral aspect of left ankle after
landing on his opponent’s foot while playing volleyball
1 hour ago. Swelling and redness were also noted in
the area.
• Problem: acute inflammation
• Goal: prevent further swelling and bleeding,
control pain
• What to Use: cryotherapy, elastic bandage
or compression garment, TENS
INTRODUCTION TO THERMAL AGENTS
MODES OF HEAT TRANSFER
CONDUCTION
➢ It occurs only between materials of different
temperatures that are in direct contact with each
other
• Modalities utilizing conduction as their mode of
heat transfer need to be in direct contact with the
patient’s skin or body part to be treated
➢ Heat is conducted from the material with higher
temperature to the material with lower
temperature
• Physical agents with higher temperature than the
patient’s skin (for example: thermotherapy
modalities like hot moist pack, heat is transferred
from the HMP to the patient’s skin causing
heating of the superficial tissues that are in
contact to the HMP)
• While, physical agents with lower temperature
than the patient’s skin (for example: cryotherapy
modalities like cold packs, heat is transferred
from the patient’s skin to the modality causing
cooling of the superficial tissues in contact with
the cold pack)
o Nirerelease ng patient’s skin yung heat
niya into the modality kaya siya
lumalamig
➢ Heat may be transferred to or from a patient by
conduction
• When one area of the body is heated by an
external thermal agent, the adjacent tissues will
also have an increase or decrease in temperature
GUIDELINES FOR HEAT TRANSFER BY
CONDUCTION
➢ The greater the temperature difference between a
heating or cooling agent and the body part it is applied
to, the faster the rate of heat transfer
• If there is a small temperature difference
between a physical agent and the body part
it is applied to, the heating will take too long
• While if there is a large temperature
difference, there will be rapid heat transfer
• The higher the temperature of a hot moist
pack, the faster the rate of heating
➢ Materials with high thermal conductivity transfer heat
faster than those with low thermal conductivity
• Metals have high conductivity
• Water has moderate conductivity
• Air has low conductivity
• It’s important to ask our patients to remove
their jewelries prior to application of thermal
agents
➢ The larger the area of contact between a thermal
agent and the patient, the greater the total heat
transfer
• For example, when a hot pack is applied to
the entire pack, or when the patient is
immersed up to the neck in a whirlpool, the
total amount of heat transfer will be greater
than if a hot pack is applied only to a small
area (like forearm, lower leg)
➢ The rate of temperature rise decreases in proportion
to tissue thickness
• When a thermal agent is in contact with a
patient’s skin, skin temperature increases the
 most and the deeper tissues are not much
heated
• The deeper the tissue, the lesser the heating
CONVECTION
➢ Occurs as the result of direct contact between a
circulating medium and another material of
different temperature
• Examples: whirlpool (water as medium),
fluidotherapy (air as medium)
• During heating or cooling by convection, the
thermal agent is in motion
• This will provide more effective heating to the
patient’s body part
CONVERSION
➢ From the word itself, it involves conversion of a
nonthermal from of energy such as mechanical,
electrical into heat, however, it does require an
intervening material to be a good transmitter of that
type of energy
• Examples: ultrasound (emits sound energy
causing the tissues within the body to
vibrate), diathermy
➢ Heating by conversion is not affected by the
temperature of the thermal agent
• It is affected by the size of area being treated,
size of applicator, efficiency of transmission
from the applicator to the patient, and the
type of tissue being treated
➢ Does not require direct contact between the
thermal agent and the body
RADIATION
➢ Involves direct transfer of energy from a material with
a higher temperature to the one with a lower
temperature without a need for an intervening
medium or contact
➢ Determined by the intensity of radiation, size of
radiation source and the area being treated, the
distance of the source from the treatment area and
angle of the source to the tissue
EVAPORATION
➢ Material must absorb energy to evaporate, thus
change from liquid to a gas or vapor form
• Example: vapocoolant spray
o When a vapocoolant spray is applied
to the body, it is heated by the warm
skin of the body so it changes from
its liquid form to a vapor state
CRYOTHERAPY
➢ Therapeutic use of cold
• In rehabilitation, we use mild cooling to
control the inflammation, pain, swelling
• It can also reduce spasticity and facilitate
movement
EFFECTS OF COLD
➢ Decrease in blood flow
• Due to smooth muscle contraction in the
blood vessels or vasoconstriction
• There is an evidence that repeating cold
application after an initial 20-minute
application for additional 2 repetitions of 10
minutes on and off can significantly lower
blood flow instead of a single 20-minute
application
➢ Decreased nerve conduction velocity
• It greatly affects the conduction of small and
myelinated fibers particularly you’re A-Delta
fibers or pain fibers
• To achieve a decreased nerve conduction
velocity, cryotherapy must be applied for 5
minutes or longer, however, it does not have
a long-term effect
➢ Increased pain threshold
• Because cold application can fully or partially
block the transmission of painful stimuli or
stimulus
➢ Altered muscle strength
• According to evidence, ice massage for at
least 5 minutes, increases isometric muscle
strength
➢ Decreased spasticity
• Spasticity is a disorder of muscle control that
is caused by the overfiring of gamma-motor
neurons
• You cannot control spastic muscles and they
remain contracted resulting to a stiff limb
• There’s an evidence that cold application for
at least 20 minutes can decrease the activity
of gamma-motor neurons thereby decreasing
spasticity
➢ Facilitation of muscle contraction
• This is used for weak muscles
• There is a technique called “quick icing”
wherein you would apply quick strokes of ice
on the area that you want to elicit muscle
contraction
• Brief cooling can facilitate alpha-motor
neuron activity which can produce muscle
contraction
 USES OF COLD
➢ Inflammation control
• Controls inflammation and its signs like bleeding,
swelling, due to its vasoconstriction effect
o Cold application causes vasoconstriction
of the local blood vessels in the area,
thereby, preventing blood flow which
reduces bleeding and swelling
➢ Edema control (same with inflammation control)
➢ Pain control
• Because it can decrease the nerve conduction
velocity particularly your pain fibers, thereby, fully
or partially blocking the transmission of the
painful stimuli
• According to evidence, cryotherapy reduces pain
and swelling and promotes short recovery period
if it is applied within the first 2 days after an injury
• That’s why, immediately after the injury, for the
first 2 days, we apply ice
• Application of cryotherapy for 10-15 minutes can
control the pain for 1-2 hours. That’s why we
instruct our patients with acute injury to apply
cryotherapy every after 2 hours for 1-2 days
• Prophylactic use or preventive measure of
cryotherapy after exercise can reduce the
severity of delayed onset muscle soreness
(DOMS)
• There are some clinics with a protocol of applying
cryotherapy at the end of the PT sessions para
hindi masyadong sumakit yung area
➢ Modification of spasticity
• Cool application can also reduce spasticity due to
its effect on the gamma-motor neuron firing
• According to evidence, cold application should be
applied for 20 minutes or up to 30 minutes to see
the effect
CRYOKINETICS AND CRYOSTRETCH
CRYOKINETICS
➢ Technique that combines the use of cold and exercise
in treatment of pathology or disease
• It involves applying a cooling agent to the point of
numbness shortly after any injury to reduce the
sensation of pain, thus, allowing the patient to
exercise
CRYOSTRETCH
➢ Application of a cooling agent before stretching
• Cold application can reduce the muscle spasm
which allows greater motion
CONTRAINDICATIONS
➢ Cold Hypersensitivity (Cold-included Urticaria)
• Appearance of smooth, slightly elevated patches
often attended by severe itching
o Patches may appear to be more pale or
more reddish than the surrounding skin
after cold exposure
o This may occur only in the area of
application or all over the patient’s body
➢ Cold intolerance
• Sever pain, numbness and color changes in
response to cold
➢ Cryoglobulinemia
• Aggregation or clustering of serum proteins
(namumuo-muo) found in the blood in the distal
circulation when distal extremities are cooled
o Dahil namumuo-muo, this can block the
circulation to the distal part of the
extremity which can lead to tissue death
➢ Paroxysmal cold hemoglobinuria
• Hemoglobin from lysed RBCs is released into the
urine in response to local or general exposure to
cold
➢ Raynaud’s Disease vs Raynaud’s Phenomenon
• Sudden pallor (paleness) and cyanosis (bluish)
followed by redness of the skin of the digits
o Raynaud’s disease has no known
cause and symptoms are bilateral and
symmetrical, even when the cold is
applied only to one area
o Raynaud’s phenomenon is caused by
other regional or systemic disorder and
symptoms occur only in the area applied
with cold
TO ASSESS OR CHECK FOR THE
CONTRAINDICATIONS
➢ Ask the patient:
• Do you have unusual responses to cold?
• Do you develop a rash when cold?
• Do you have severe pain, numbness, and color
on your hand and fingers changes when exposed
to cold?
• Do you see blood in your urine after being cold?
Over regenerating peripheral nerves
➢ Ask patient:
• Do you have any nerve damage in this area?
• Do you have any numbness or tingling in this
limb?
➢ Assess
• Sensation
Over an area with circulatory compromise or
peripheral vascular disease
➢ Ask patient:
• Do you have poor circulation in this limb?
➢ Assess
• Skin color and temperature (usually cold and
pale)
 PRECAUTIONS
➢ Over the superficial branch of a nerve
• Cryotherapy application can cause a decrease in
the nerve conduction velocity or it can cause
conduction
• Monitor patient for symptoms of conduction like
distal numbness, tingling sensation
• Discontinue if these symptoms occur (example:
naka-Indian seat, then namamanhid yung paa)
➢ Over a superficial open wound
• New tissue covering the wound is sensitive to
cold and it may delay the healing (not too cold)
• You cannot apply it on deep wound
➢ Hypertension
• Because cold application can cause transient
increase in blood pressure so you have to monitor
your patient closely
• If patient’s BP increases within the normal
boundaries (or what is normal for them),
discontinue application
➢ Poor sensation or mentation
• Because if the patient has poor sensation or
mentation, he may not be able to report any
discomfort or the sensation he is feeling
➢ Very young and very old patients
• Because these patients have often limited ability
to communicate or have impaired sensation
ADVERSE EFFECTS OF CRYOTHERAPY
TISSUE DEATH
➢ Tissue damage can occur when tissue temperature
reaches 15°C (59°F)
➢ Frostbite does not occur until skin temperature drops
to 4°C - 10°C (39°F - 50°F) or lower
➢ Can be caused by prolonged vasoconstriction,
ischemia, and thrombosis in the smaller blood
vessels
➢ It’s important to limit the application less than 45
minutes (usually until 20 minutes application in clinic)
APPLICATION TECHNIQUES
➢ Applying frozen gel packs or ice packs for 20 minutes
reduces the temperature of skin and tissues up to
2cm deep
➢ Patient will usually experience the following
response:
• Intense cold
• Burning sensation
• Aching sensation
• Analgesia
• Numbness
COLD PACKS AND ICE PACKS
➢ Cold packs are usually filled with a gel composed of
silica or a mixture of saline and gelatin and are usually
covered with vinyl
➢ The gel is formulated to be semisolid at between 0°C
- 5°C (32°F - 41°F)
➢ Temperature of cold pack is maintained by storing it
in specialized cooling units or in a freezer at -5°C
(23°F)
➢ It should be cooled for at least 30 minutes between
uses and for 2 hours or longer before the initial use
➢ Patients can also make their own cold packs from
plastic bags filled with water and rubbing alcohol
cooled in a home freezer
• The ratio of the water to the rubbing alcohol
should be 4:1 because addition of alcohol
decreases the freezing temperature so that it is
semisolid and flexible for it to conform to the body
part
➢ Ice packs are made of crushed ice placed in a plastic
bag
• If it’s not available, substitute can be plastic bags
of frozen vegetables
➢ Cold packs are stored on a cooling unit or sometimes
in the refrigerator
➢ ADVANTAGES
• Very easy to use
• Inexpensive
• Require brief use of the clinician’s time (pwedeng
si clinician iapply niya lang then may gagawin
siyang iba habang nakaapply yung cold packs or
ice packs sa patient)
• Requires low level of skill (kumuha ka lang ng ice
pack, babalutan mo lang ng cloth, then isesecure
sa patient’s body part)
• Can cover moderate to large areas of the body
• Can be applied to an elevated limb (which is good
to further reduce the swelling)
➢ DISADVANTAGES
• The pack must be removed to inspect the area
being treated (to inspect the patient’s skin for any
adverse effects or color changes or adverse
reaction, you need to remove the pack)
• Some patients may not tolerate the weight of the
pack
• Pack may not be able to maintain good contact
on small or highly contoured areas
• Long duration of treatment compared with ice
massage
ICE MASSAGE
➢ Ice cups are made by freezing small paper or
Styrofoam cups of water
➢ Frozen water popsicles are made by placing a stick
or tongue depressor into the water cup before
freezing
➢ ADVANTAGES
• Treatment area can be observed during the
application unlike cold packs or ice packs
• Technique can be used for small and irregular
areas or highly contoured areas like your thumb,
fingers
• Short duration of treatment (5 minutes)
• Inexpensive
• Can also be applied to an elevated limb
➢ DISADVANTAGES
• Time consuming for large areas
• Requires active participation of the clinician
throughout the application
CONTROLLED COLD COMPRESSION UNIT
➢ Alternately pump cold air and water into a sleeve that
is wrapped around a patient’s limb
• It provides compression and has a cooling effect
which is good to reduce the swelling
➢ Temperature of water can be set at between 10°C -
25°C (50°F - 77°F) to provide cooling
➢ Compression is applied by intermittent inflation of the
sleeve with air
➢ Most commonly used after surgery to control post-
operative inflammation and swelling
➢ ADVANTAGES
• It allows simultaneous application of cold and
compression
• The temperature and the compression force are
easily and accurately controlled
• It can be applied to large joints?
➢ DISADVANTAGES
• The area being treated cannot be seen during
treatment
• It is expensive
• It is useable only for extremities and cannot be
used for trunk and digits
VAPOCOOLANT SPRAYS AND BRIEF ICING
➢ Ethyl chloride and Fluori-Methane
• Were used for rapid and brief superficial cooling,
however, Ethyl chloride is volatile and flammable
• Ethyl chloride can cause excessive reduction in
temperature and can produce anesthetic effects
when inhaled
• Fluori-Methane can provide effective cooling
without excessive reduction in temperature,
however, it can damage our ozone layer
• The company developed a vapocoolant spray
that is unflammable and does not cause damage
to the ozone layer (spray and stretch)
➢ Spray and stretch
• Vapocoolant spray is applied in parallel strokes
along the skin overlying the muscles
• When spraying, you need to hold the can 12-18
inches away from the patient’s skin with an angle
of 30°
➢ ADVANTAGES
• It is used for brief duration of cooling
• Has a very localized area of application
➢ DISADVANTAGES
• It is only used for brief localized and superficial
application of cold before stretching

DOCUMENTATION

➢ Type of cooling agent used

➢ Area of the body treated
➢ Treatment duration
➢ *Patient positioning
➢ *Response to intervention

Example:

• Cold packs on lateral aspect of (L) ankle x 10

minutes
• Cold packs on lateral aspect of (L) ankle x 10
minutes with the patient in supine, (L) LE
elevated. Patient reported numbness in the area
after application and a slight redness of the skin
was observed.