PHYSMOD_LEC - Superficial Cold & Heat

Cryotherapy

“Cryos” = ____, cold; “therapeia” = _____ → Cold Therapy

It is the use of ice or cold applications for therapeutic purposes

ICE , to treat

Effects of Cold Application

Hemodynamic Effect

Initial response: _________

Prolonged exposure to cold : ________ - response to hypothermia(self preservation - sympathetic) or hunting response ( To preserve body systems )

Indirectly : ___ in vasodilator release ( histamines and prostaglandins) = vasoconstriction & ___ blood viscosity ( reduce circulatory rate)

Vasoconstriction/ DEC blood flow

cold induce vasodilation ( most likely to occur in distal extremities like finger/toes)

DEC, INC

Effects of Cold Application: Hemodynamic Effect

(1) COLD → cutaneous thermoreceptors → dorsal root ganglion → INC sympathetic activation → vasoconstrict → DEC Blood Flow (INDIRECT EFFECT)

(2) COLD → cutaneous thermoreceptors → Smooth muscle contraction → vasoconstrict → DEC Blood Flow (DIRECT EFFECT)

(3) COLD → INC blood viscosity → DEC Blood Flow

ANALYZE

Effects of Cold Application

Neuromuscular Effect

• ____ in nerve conduction velocity,

  • DEC ____ small fibers( myelinated → A delta ) , INC for _____ large fibers

  • Reducing transmission of pain signals

  • Can happen if applied to skin 5 minutes or longer

• ___ spasticity

  • Dec gamma motor activity (initial) & afferent spindle and gto (later)

  • 10-30minutes

• ____ pain threshold ( reduce pain)

  • Gate control theory , interruption of pain spasm cycle

  • Reduction of edema, reduction of sensory nerve

DEC,Dec & Inc

myelinated;unmyelinated

Effects of Cold Application

Neuromuscular Effect

• Altered muscle strength

  • INC strength if _____ (sympathetic)

  • _____ : DE muscle strength

• Facilitation of muscle contraction

  • Quick application of icing -> facilitate _______ ( for flaccid muscles and upper motor neuron lesions)

  • Application of cold for 5-30 mins causes a ________ in tone, but if it is applied quickly, there will be facilitation of the tone

5mins or less ;5-30mins

alpha motor neuron

reduction

Effects of Cold Application

Metabolic Effect

• ____ metabolic rate

  • Controls ____ inflammation (edema)

    • not recommended when healing is delayed because it will prolong process

  • Inhibits activity of ______ for OA

  • Reduce level of ____ in the blood for RA

Dec

acute
cartilage degrading enzymes

histamine

MODES OF ENERGY TRANSFER

_______ - 2 surfaces of different temperatures come into contact, it tends to lose some heat

______ - If there is a moving fluid, either air or water, you also lose heat especially if the moving fluid is cooler in temperature

______ - Each time we sweat and it evaporates, we are losing heat in our body

________ - Too much exposure to this causes heat but less exposure will promote heat loss

_________ - Loses heat inside the body ; breathing

Conduction

Convection

Evaporation

Radiation

Respiration

Clinical Indications for Cryotherapy

1. _______ Control ( > 15 mins)

   1. accelerates recovery from injury

   2. reduces heat, redness, edema , pain and loss of function

   3. Apply immediately after an injury

   4. Helpful for OA & RA

   5. Reduce ____

2. _____ Control

   1. apply ASAP

   2. Not effective in controlling edema caused by immobility and poor circulation

   3. Reduces intravascular fluid pressure by reducing blood flow into the area via vasoconstriction and increased blood viscosity

3. _____ Control ( 10-15 mins)

   1. reduce sensation of pain

4. Modification of Spasticity

   1. reduce spasticity in patients with Upper motor neuron dysfunction

   2. 5mins can DEC deep tendon reflex

5. Symptom management in Multiple Sclerosis

   1. decreases tremor

   2. reduce fatigue, muscle weakness, visual dysfunction and postural instability

Inflammation

Reduce DOMS

edema

Pain

Clinical Indications for Cryotherapy

6. Facilitation

   1. quick icing to elicit desired motor patterns

7. Cryokinetics and cryostretch

   1. ____ technique that combines the use of cold and exercise to treat pathology or disease. Apply cold until numbness to dec pain

   2. ____ application of cooling agent before stretching ( reduce muscle spasm = Greater ROM)

8. Treatment of acute burns

   1. As a first aid for superficial burn injuries, need to apply flowing cool water on the injury

9. Treatment with joint mobilization, deep friction massage, compression, elevation, workout

   1. PRICE

Cryokinetics

Cryostretch

Contraindications of Cryotherapy

• Cold hypersensitivity/cold induced urticaria (rashes)

• Cold intolerance

• Cryoglobulinemia

• Paroxysmal cold hemoglobinuria

  • hemoglobin is released to urine due to cold exposure

• Raynauds disease/phenomenon

  • cyanosis due to cold exposure

• Smooth muscles cannot adapt to cold ;no vasoconstriction or dilation responses

• Over a regenerating peripheral nerve

  • dont apply directly because it will alter never conduction

• Over an area with circulatory compromise or peripheral vascular disorder

  • aggravate condition by causing vasoconstriction and INC blood viscosity

  • Edema that results from impaired circulation may be increased by cryotherapy

Precautions of Cryotherapy

• Over a superficial main branch of nerve

  • applying directly may cause nerve conduction block

• Over an open wound

  • delay healing by reducing circulation

• Hypertension

  • INC BP

• Poor sensation or mentation

• Extreme ages of patients

  • very young or old frequently have impaired thermal regulation

Adverse effects of Cryotherapy

• Tissue death from ischemia

• Frost bite ( -4 to 10 C )

To avoid damage to soft tissue or nerves, cold shouldnt be applied for ______. Cryotherapy should be applied for only ______ when goal is vasoconstrict (reflex vasodilation and INC blood flow may happen to distal extremities)

no longer than 45 minutes

10-20 minutes

Application of cryotherapy produces 4 stages of sensation:

• cold

• Burning

• Aching

• Numbness/analgesia ( this is the goal)

Application of Cryotherapy

________

• Filled with gel composed of silica or mixture of saline and gelatin and usually covered with vinyl

• Temp of cold pack is maintained in a freezer at ___

• Alternative : ___ ( water : rubbing alcohol) at home

• Duration : ______ (if not yet achieved, modality problem or patient might have other implications better use other modalities)

• Should be cooled at least ___ minutes between uses for ___ hours or longer before initial use

• Once achieved numbness, end the application  

Cold Packs / Cold Gel Packs

-5 C

4:1

10-20 minutes

30 minutes; 2 hours

Application of Cryotherapy: Advantages of Ice Packs

• Easy to use

• Inexpensive 

• Brief use of clinicians time

• Low level of skill required / quicker to apply

• Covers moderate to large areas

• Can be applied to elevated limb

Application of Cryotherapy: Disadvantage of Ice Packs

• pack must be removed to check area (blood flow check)

• Patient may not tolerate the weight of pack

• Check every 5minutes

• Pack may have inadequate contact on certain areas

• Longer duration compared to ice massage

Application of Cryotherapy

__________

• Ice cups or frozen water popsicles

• Done over a small area before deep pressure massage

• Benefit : Skin temperature will not drop below ____

• Smoothen surface of ice first

• Duration: ____ minutes until patient experience analgesia

Ice massage

15 C

5-10 minutes (3-5 kay merida)

Application of Cryotherapy: Advantages of Ice Massage

• Treatment area can be observed during application

• Short duration of treatment

• Inexpensive

• Can be applied to an elevated limb

• Can be used for small and irregular areas

Application of Cryotherapy: Disadvantages of Ice Massage

• Time consuming for large areas

• Requires active participation by the clinician or the patient throughout application

Application of Cryotherapy

_______

• Ice crushed in plastic bag

• More aggressive cooling

• Duration same as cold packs ( 10-20 minutes)

Ice pack

Application of Cryotherapy

_________

• Cooled water is circulated through the sleeve which is applied to the extremity which is then inflated intermittently 

• Temp : ___

• Used for inflammation and edema post operatively and in other related edema circumstances 

• Applying cold with compression after surgery in this manner is more effective to reduce swelling, pain, and blood loss and assist in regaining ROM

Controlled Cold Impression Unit

10-25 C

Application of Cryotherapy : Controlled Cold Impression Unit Advantages

• Allow simultaneous application of cold and compression

• Can applied to large joints

• Temperature and compression force are easily and accurately controlled

Application of Cryotherapy : Controlled Cold Impression Unit Disdvantages

• Expensive

• Treatment site cannot be visualized during treatment

• Usable only for extremities

• Cannot be used for trunk and digits

Application of Cryotherapy

__________

• Combination of ethyl chloride & fluori-methane

• Used to achieve brief and rapid cutaneous cooling by evaporation before stretching

• Spray and stretch, instant ice and pain ease

• Treatment of Myofascial pain syndrome, trigger points , restricted motion and minor sports injuries

• Application : bottle is upright and held at __ degrees approx. 30-35cm from the skin at a rate of 10cm/sed (4inches/sec)

• For trigger points: unidirectional sweep along the muscle with trigger points then over the area of referred pain

• To increase ROM: the entire length of the muscle should be covered ___x at a rate of 10cm/sec. If further treatment is required, the skin should be rewarmed first to avoid frosting

Vapocoolant spray

30 degrees

2-3

Application of Cryotherapy : Vapocoolant Spray Advantages

• Brief duration of cooling

• Very localized area of application

Application of Cryotherapy : Vapocoolant Spray Disadvantages

• Limited to use for bried,localized, superficial application of cold before stretching

• Other means of applying cryotherapy

Application of Cryotherapy

________

• Used in patients with CNS disorder

• Quick swipes with an ice cube iver the belly of the involved muscle performed ____ times have a facilitatory effect which might occur immediately or 27-42 mins after application 

• A icing : __ swipes, wipe every after swipe

• C icing : hold ice for __ seconds, 

Quick Icing

3-5x

3 swipes

3-5

Application of Cryotherapy

____________

• Convenient for emergency use

• Consist of 2 chemical substances one in a small vinyl bag within a larger bag

• Should remain in tank at least hrs before the first use and at least __ mins for subsequent uses

• Stored in refrigeration tank with temp at -12.2 c to -9.4c

• Cover it with thin pc of cloth and make it wet  before applying on the area

• Duration :___ minutes

Chemical cold packs

24 hours ; 30mins

10-15

Application of Cryotherapy

____________

• Terry cloth towel soaked in a bucket of crushed ice or slush mixture or frozen wet towels

• Frozen wet towels

• Very messy & Inconvenient (towels must be changed after 4-5 minutes)

• Duration: ____ minutes

Ice towels

10 - 15

Application of Cryotherapy

_______________

• Most practical if cooling of distal extremities is desired

• Ensure circumferential cooling of the extremities

• Water temp is 13 c to 18 c

• Lower temp is used from cryokinetics

Cold Baths

Application of Cryotherapy

______________

• Indicated for conditions in which exercise of the injured part during cold treatment 

• Most intense application of cold

• Temp : 10-16 c

• Duration : ____ minutes

Cold Whirlpool ( moving water compared to cold bath)

5-15

Cryotherapy Documentation

P: _______ on _______ in ______ x ______ to ________

<application technique> on <body area > in <position >x <duration > to <rationale>

Superficial Cold & Heat

This therapeutic application of heat is used to primarily destroy malignant tissue or treat cold-related injuries. It is used to control pain, INC soft tissue extensibility and circulation, and accelerate healing.

Thermotherapy

Thermotherapy : Effects of Heat

Hemodynamic Effects

• ______

  • INC rate of blood flow ( can occur in more distal and deeper vessels in the muscles & improve vascular endothelial function)

  • To INC blood flow in skeletal muscle, exercise / ultrasound or diathermy can be used

  • INC Temperature

    • Cutaneous thermoreceptors → dorsal root ganglion → DEC Sympathetic → vasodilate (INDIRECT)

    • Cutaneous thermoreceptors → Smooth muscle relaxation → vasodilate (DIRECT)

    • Inflammation → Vasodilator (Histamine and prostaglandin Release) → vasodilate

  • _____ and _____ that happens in response to INC tissue temp protect the body from excessive heating and tissue damage by convective cooling

Vasodilation

cutaneous vasodilation & increase blood flow

Superficial heating agents do not heat to the depth of most muscles. To heat deep muscles, use exercise or deep-heating modalities such as ultrasound or diathermy.

Thermotherapy : Effects of Heat

Neuromuscular Effect

• ___ nerve conduction velocity ( by ___ for every 1 C° rise

• ___ pain threshold ( indirect : DEC ischemia and muscle spasm, direct : gating theory; DEC ______)

• Altered muscle strength ( initial 30min = dec endurance & strength, > 30 min = muscle strength recovers ; delayed in strength is thought to be caused by INC in pain threshold)

• __ firing rate ( DEC in firing rate of ______ ________ & ______ while INC for ____ fibers) 

• This should be applied with caution to those with demyelinating conditions

INC - 2m/s

INC

DEC pain reception

DEC - type 2 muscle spindle motor & gamma efferents while INC for Ib

Thermotherapy : Effects of Heat

Metabolic Effect

• __ metabolic rate

  • Accelerate healing of chronic wounds

  • Inc collagenase activity -> destroy articular cartilage

  • 39-43 c = inc rate of endothermic chemical reactions

  • Beyond 45 c protein constituent

• Shift of O2- HGB dissociation curve to the __

  • Makes o2 available for tissue repair (wound healing)

• Altered tissue extensibility

  • inc temp -> ___ tissue/ collagen extensibility

  • Achieved when tissue heating is maintained at ___ C° for ___ mins

INC

right

inc

40-45 for 5-10mins

Thermotherapy :Methods of Heat Gain

Conduction : hot packs

Convection : fluidotherapy

Radiation : UV/ diathermy

Thermotherapy : Application

_________

• Stored in hmp tank / hydrocollator at 70-75 C°; made of bentonite covered with canvas

• Initial heating : ___

• Reheat between uses : ____

• Wrap the hot pack in 6-8 layers of dry towels

  1. Terry cloth (new) : equivalent to _ layers

  2. Old : equivalent for __ layers

• Intensity : mild comfy moist warmth

• Duration : ____ minutes

Hot moist pack

2hrs → 30minutes

4 / 1-2 layers

15-20

Hot packs Advantage

• Easy to use

• Inexpensive materials (packs and towels)

• Brief use of clinician's time

• Low level of skill needed for application

• Can be used to cover moderate to large areas

• Safe because packs start to cool on removal from the water cabinet

• Readily available for patient purchase and home use

Hot packs Disadvantage

• Hot pack must be moved to allow observation of the treatment area

• Requires towelling

• Patient may not tolerate the weight of the hot pack

• Pack may not be able to maintain good contact with small or contoured areas

• Active motion is not practical during treatment

• Moderately expensive equipment (heated water cabinet) is needed

• Declining heating pattern

Thermotherapy : Application

_______________

• Warm, melted paraffin wax

• Wax to mineral oil ratio : 6:1 or 7:1

  • To reduce melting temp from 54 c to 45-50c 

• Can be applied directly to skin due to low specific heat and thermal conductivity 

• Advantageous to irregularly contoured areas ( distal extremities )

• Stored at 52-57 c

• Intensity :_________

• Duration: _______

Methods:

• Dip and wrap – ____ dips

• Dip immersion – ___ minutes

• Paint/Brush method

Paraffin wax bath

20-30 minutes

mild comfy moist warmth

6-10;20

PWB Advantages

• Maintains good contact with highly contoured areas

• Easy to use

• Inexpensive

• Body part can be elevated if dip-wrap method is used

• Oil lubricates and conditions the skin

• Can be used by the patient at home

PWB Disadvantage

• Messy and time-consuming to apply

• Cannot be used over an open skin lesion because it may contaminate the lesion

• Risk of cross-contamination if the paraffin is reused

• Part in dependent position for dip-immersion method

Thermotherapy : Application

_______________

• Dry heating agent that transfers heat by ____

• Both the temperature and the amount of particle agitation can be controlled by the clinician

• Cabinet either finely ground

Fluidotherapy

convection

Fluidotherapy Advantages

• Patient can move during the intervention to work on gaining AROM

• Minimal pressure applied to the area being treated

• Temperature well controlled and constant throughout intervention

• Easy to administer

Fluidotherapy Disadvantages

• Expensive equipment

• Limb must be in dependent position in some units, increasing the risk of edema formation

• The constant heat source may result in overheating

• If the corn cob particles spill onto a smooth floor, they will make the floor slippery

Thermotherapy : Application

_______________

• emit electromagnetic radiation with a wavelength of 770 to 10nmn

• Currently used in rehabilitation emit __ with mixed wavelengths of approximately 780 to 1400 nm and peak intensity at approximately 1000 nm.

• Human skin allows maximum penetration of radiation with a wavelength of ___ nm

• With the same radiation and lamp positioning, ___ skin will absorb more IR and therefore will increase in temperature

• duration : ____ minutes

Infrared radiation

IR-A

1200

dark

20-30 minutes

IR Lamp Advantages

• Does not require contact of the medium with the patient, which reduces the risk of infection and the possible discomfort of the weight of a hot pack and avoids the problem of poor contact when highly contoured areas are treated

• The area being treated can be observed throughout the intervention

• Can be used to treat larger areas

IR Lamp Disadvantages

• IR radiation is not easily localized to a specific treatment area

• It is difficult to ensure consistent heating in all treatment areas because the amount of heat transfer is affected by the distance of the skin from the radiation source and the angle of the beam with the skin, both of which vary with tissue contours and may be inconsistent between treatment sessions

• Dehydration due to excessive perspiration

Infrared Radiation

_____ from a glowing source like tungsten or carbon filament material

____ from a non glowing source like carborundum with metal reflector

Luminous IRR

Non-luminous IRR

Infrared Radiation

Distance : _______ ;_______

Pre heating :________;_______

Intensity : ________

Duration: _______

Luminous vs non luminous

45-60cm;74-91cm

Immediately or 5min warm up ; 5-10mins

15-30minutes (20minutes)

Laws in Applying Radiation

1. _____ cosine law : use head perpendicularly

2. _______ law : appropriate distance of the machine for treatment

3. Law of____ : waves must absorbed to be beneficial, ensure proper absorption

4.______ principle : dosage determination (intensity = warmth)

5. ________ law of reciprocity : adjustment of parameters in treatment

Lamberts

Inverse square

gorthus draper

Arnd chultz

Bunsen-Roscoe (Intensity and duration of the dose is inversely proportional )

RADIATION

• The one closer to the visible light has shorter wavelength but the one farther has a longer wavelength.

• The wavelength and frequency are inversely proportional

• shorter wavelength = higher frequency

hehe

Adverse Effects of Heat

• Burn injuries

  • always check every 5minutes ( blanching)

• Blister formation

• Bleeding

• Skin & Eye damage from IRR

• Fainting

  • DEC BP → DEC HR ( lower head and raise feet if patient faints)

Thermotherapy : Indications

For ALL Superficial Heating Modalities

• Pain

• Subacute and chronic conditions

• Muscle Spasm

• Stiff Structures ( tissue extensibility)

• Accelerate tissue healing ( circulation and enzymatic activities)

Thermotherapy : Indications

Specific to IRR

• Pressure to sores

• Psoriasis

• Adjunct to electrical stimulation, to DEC skin impedance

Thermotherapy : Contraindications

For ALL Superficial Heating Modalities

• Recent or potential Hemorrhage

• Thrombophlebitis ( thrombus formation)

• Malignant Tumor

• Metal in the area

• Impaired sensation

• Impaired mentation

Thermotherapy : Contraindications

Specific to IRR

• Acute dermal conditions

• Superficial metals in the area

• Erythema ab igne

• Over the eyes

• Cardiac Insufficiency

Thermotherapy : Precautions

For ALL Superficial Heating Modalities

• Acute injury or inflammation

  • Heat should not be applied within the first 48-72 hrs after an injury

• Pregnancy

  • If pt is pregnant, heat should not be applied to the abdomen or low back, and should not be immersed in a warm or hot whirlpool.

• Impaired circulation

• Poor thermal regulation

• Edema

• Cardiac Insufficiency

• Metal close to the target area

• Over areas with recently applied topical counterirritants

• Demyelinated nerves

  • Application of superficial heat (e.g. fluidotherapy, heat lamp, and water bath) has been shown to cause conduction block when applied to demyelinated peripheral nerves

• Impaired sensation

• Impaired mentation

Specific to IRR

• Too much perspiration

Thermotherapy: Documentation

HMP/ PWB/ Fluidotherapy

<Modality> on <body area> in <position> x <duration> to < rationale>

Thermotherapy: Documentation

IRR

< Type of IRR equipment > at <distance> on <body area> in <position> x < duration> to < rationale>

__________

• Applied by alternately immersing an area, generally a distal extremity, first in warm or hot water and then in cool or cold water

• Used to decrease pain and increase flexibility while avoiding edema

• Used for patients with chronic edema, subacute trauma, inflammatory conditions, sprains,strains, tendinitis, hyperalgesia

• Hydrotherapy approach using cold and warm water

  • Warm water : ___ C

  • Cold water: ____ C

• Technique

  • Hot (3-4 mins) → Cold (1 minute)

  • Repeat cycle for __ times → (____ minutes)

  • End with warm water

Contrast bath

38-44 C

10-18 C

5-6 → 25 - 30 minutes

Contrast Bath Advantage

• May promote increased superficial blood flow

• Provides good contact with contoured distal extremities compared with other thermal agents

• May help to provide pain control without aggravating edema

• Allows movement in water for increased circulatory effects

Contrast Bath Disadvantage

• Limb is in a dependent position, which may aggravate edema

• Some patients do not tolerate cold immersion

Contrast Bath: Documentation

Contrast bath on ______ in ________ x ______ for warm x ______ for cold x _______ to ________

body area → position → temperature → temperature → total duration → rationale

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