Cold Pack Procedure PDF

Lect HO\#1 - PTH 121 Unit 3 - Superficial **Cold** and Heat [Reference:] Michlovitz: Ch2 Fairchild: Ch3 O'Sullivan: Ch25 **Learner Objectives:** Upon completion of this unit, including lecture and laboratory attendance, completion of reading assignments and review of handout materials, the stu...

Lect HO\#1 - PTH 121 Unit 3 - Superficial **Cold** and Heat [Reference:] Michlovitz: Ch2 Fairchild: Ch3 O'Sullivan: Ch25 **Learner Objectives:** Upon completion of this unit, including lecture and laboratory attendance, completion of reading assignments and review of handout materials, the student will be able to: A1. Identify the different modalities used for superficial cold and heat. A2. Describe the cooling and heating methods of radiation, conduction, convection, and evaporation. A3. Characterize each thermal modality according to its method of cooling or heating. B1. Discuss the physiological effects, treatment goals, indications, contraindications, precautions, and treatment procedures for the following a. b. Ice massage c. Cold packs d. Ice compression pumps (Game Ready, Therm-X) e. Contrast baths f. Vapocoolant spray g. Hot pack h. Paraffin i. Fluidotherapy j. Infrared B2. Demonstrate safety precautions and knowledge of equipment maintenance for the modalities noted in B3. Given a patient scenario, determine and demonstrate the appropriate application of a thermal modality (noted in B1 above) based on the criteria on the check-off grading rubric. (7D15, 7D17, 7D18, 7D19, 7D20, 7D21, 7D23c, 7D23g, 7D23h) B4. Based on the patient scenario in B3, document a full SOAP note for the treatment (thermal modality) C1. Describe the therapeutic use of ultraviolet light in physical therapy. C2. Discuss the physiological effects, treatment goals, indications, contraindications, precautions, and treatment procedures for ultraviolet light. (7D21) C3. Given a patient scenario, describe how to determine the MED and progression of a treatment session. -------------------------------------- **What are therapeutic modalities?** -------------------------------------- - Represent the administration of [thermal, mechanical, acoustic, electromagnetic (includes light) energies] for a specific therapeutic effect. Indications: ↓ pain, ↑ range of motion, ↑ tissue healing or ↑ \*muscle recruitment recall "motor unit" = a single cell + axon + all fibers it innervates ↑muscle recruitment = ↑ motor unit = ↑ contraction (strength) ----------------------------------------------- **Types of cooling modalities used in rehab** ----------------------------------------------- - Ice/Cold packs -- ice cubes or crushed ice in water, (water: alcohol=3:1) - Commercial cold pack -- "Coldpac" (\~ -5°C) - Instant cold packs --one time use, disposable; works with a chemical reaction - Ice Compression Pump -- ice/water flowing through tubing to pack (Cryocuff; Polar Care-circulating water, Game Ready, Therm-X) - Ice massage -- ice cube/ice cup - Vapocoolant spray ("Spray & Stretch") Contrast baths (heat and cold) ------------------------------ **Methods of heat transfer** ------------------------------ 1. **Radiation**- (non-thermal and thermal use) Classified according to the specific frequency of the electromagnetic (EM) wave, therapeutic EM radiation includes Short Wave Diathermy (SWD), infrared radiation (IR), and ultraviolet (UVA and UVB) radiation. (Ch 6) 2. **Evaporation**- cooling that occurs when a [liquid] is transformed into a [gaseous] state (Example: Vapocoolant sprays such as "Spray and Stretch" (rx needed; penta- and tetrafluoromethane) "Instant Ice" (rx not needed) are nonflammable, liquid aerosol skin refrigerants, as the liquid leaves the pressurized canister, it begins to evaporate. When this transition occurs, the [stream cools] and extract heat upon contact with the skin. 3. **Conduction**- transfer of heat by direct interaction of the molecules in the warmer area with those in the cooler area (Example: ice or cold pack over an area). Usually medium is solid material (such as ice pack) 4. **Convection**- heat abstraction occurs when there is direct contact between the skin and moving fluid particles (Example: cold whirlpool-water moves over skin via turbines that circulate the water). **Quiz:** 1. Which is the faster method of heat transfer? Convection vs Conduction. 2. In the order of faster -\> slower method of heat transfer? Conduction, Convection, Radiation. (Think how do I get warmer the fastest?) ------------------------------------ **Cold Therapy Modalities (Ch 2)** ------------------------------------ - The use of cold to induce therapeutic and physiological responses that result from a decrease in tissue temperature. - Cooling is accomplished by [removing or abstracting heat] from an object (NOT adding cold). - Superficial effect: [1-3 cm] depending on temperature gradient and exposure time. More intense cold & longer exposure times result in greater decreases in tissue temp & deeper penetration. - Most significant cooling occurs [up to 1cm] -- [superficial] structures-nerve endings - Cooling of muscles and joints only possible when they are located superficially - Primary method of heat transfer (heat abstraction/cooling) are [**conduction** (= direct physical contact)] and [**convection** (= movement of molecules, air/wind or water)] 1. "Ice pack over an injured area becomes cooler" = conduction vs convection 2. "Playing in a pool 77-82 °F, you will be freezing in 30mins" = conduction vs convection Note: Cool or cold immersion use [both conduction and convection] methods for heat transfer. **Class activity -- state the method(s) of cooling (or *heating*) for each modality.** Ice/Cold packs Commercial cold pack Instant cold packs Ice Compression Pump Ice massage Vapocoolant spray Contrast baths (later in HO) *Hot pack* *Paraffin* *Infrared* *Fluidotherapy* Factors Influencing Response to Cold Therapy: see **Box 2.1 Michlovitz** - Temperature difference between cooling object and the soft tissue - Time of exposure (duration) - [Thermal conductivity] of area being cooled - Type and size of cooling agent - Total body surface area cooled - Activity level (increased activity → increased circulation → faster rewarming) - Ability of cooling agent to maintain its temperature Trying to verify with NPTE if they use F or C in board exam. (Bean 9/13/24)  OR F = (9/5 × C) + 32 C = 5/9 (F -- 32) The rate of heat transfer by conduction: *D = Area × **k** × (T1 -- T2)/thickness of tissue* *D is the rate of heat loss (calories/second). Area is the extent of body surface cooled or heated (cm2), and [k is the thermal conductivity of tissues] (calories/second/cm2 ×°C/cm2) (Table 2-2), and T1 and T2 are the temperatures of the warm and cool surfaces (°C).* - Thicker tissue =\> heat loss (cooling effect) is less vs more? - Bigger area =\> heat loss (cooling effetct) is less vs more? A screenshot of a graph Description automatically generated **Quiz**- Which material is the best agent as a cooling material? (note, bone and muscle are equal in terms of heat conductivity) From our text... "Most clinicians will agree that, in the acute phase (24 to 48 hours), cold should be the modality of choice and should be administered as soon as possible after injury. Even though cold may be uncomfortable for the patient during the first few minutes, pain will ultimately be reduced, and edema, inflammation, and muscle spasm will most likely be lessened". Beyond the acute phase of injury, heat may be the agent of choice for intervention. But in many cases, [cold has been a successful part of a therapeutic regimen to facilitate muscle contractions], reduce joint pain caused by arthritis, and [lessen muscle spasm]. One study demonstrated that the use of [repeated cold applications in individuals with chronic lateral epicondylitis was as effective as exercise or exercise plus cold in reducing pain and improving function]." (p.35) --------------------------- **Goals of cold therapy** --------------------------- Limit edema formation Reduce pain Facilitate muscle relaxation Limit secondary hypoxic tissue injury **Physiological Effects of Tissue Cooling** Study \#1 in 1946. Orthopedic surgical procedures (n=824 cases) Group 1 (n=479): no cooling Group 2 (n=345): ice bags over their soft casts for a 48-hour period; replaced every 4 hours - Group 2 required fewer swelling-related splitting of casts (5.31%) compared with the non-iced group (41.3%). - Group 2 had less inflammation and fewer fevers above 101°F (38.3°C) - No subject in the iced group had apparent hematomas or hemarthrosis. (vs 16 of those in the group that received no ice) - Fewer narcotics were administered to those subjects who were treated with ice, indicating that their pain was less. Study \#2 for TKA (systematic review) - No substantial effect on the variables of (blood) transfusion rate, pain on POD\# 1 and 3, use of analgesics, and length of hospital stay. - The addition of cryotherapy had a [significant effect on postoperative blood loss], [pain on POD\# 2], and ↑ [knee ROM (ext/flex) at dc]. Study \#3 for THA (systematic review) - Similar results for patients following TKA and THA with [decreased blood loss] and [decreased pain on postoperative day 2]. Study \#4 for [severe ankle sprain] - Treatment was continued for a minimum of 3 days for all patients. - The early cold (within the first 36 hours) returned to full activity (running and jumping without pain) an average of [8 days sooner] than those treated with heat (1) or delayed cold (2). - The time at which cryotherapy is initiated following trauma can influence the time course for functional outcome. ----------------------------------- **Effects of cold to the tissue** ----------------------------------- 1\. Vasoconstriction of superficial blood vessels -\> leads to [↓] in local blood flow 2\. Cooling of tissue can occur to depths of 1-3 cm (recall most significant cooling occurs up to 1 cm-superficial structures, nerve endings) 3\. [↓] elasticity and [ ↑]viscosity of tissues (reverse of heat) 4\. [↓] metabolic rate 5\. [↓] oxygen demand of tissues 6\. [↓] fluid in interstitial space by affecting cell wall permeability 7\. [↓] accumulation of metabolites and chemical irritants thus [ ↓] inflammatory reactions 8\. [↓] nerve conduction velocity and sensitivity of free nerve endings -- this results in numbness and [ ↓] pain ([increase] pain threshold) 9\. [↓] mm spasm due to pain reduction 10\. [↓] HR and [↓] RR More to consider... 11\. ↓ Metabolic rate; slows production of metabolites; ↓ oxygen demand in tissues (\#1 & \#2 = ↓ edema) 12\. ↓Temp within joint - after prolonged exposure - can ↓ activity of cartilage destroying enzymes 13\. ↓ Nerve conduction velocity, ↓ sensitivity of free nerve endings → numbness 14\. ↑ Pain threshold 15\. ↓ Ms spindle activity → ↓ Spasticity by decreasing activity of muscle spindles 16\. ↓ Ability to perform rapid movements - 2° ↑ ms viscosity or ↑ contraction/relaxation times 17\. \* ↓ Force output of muscles following ice. 18\. ↓ inflammatory response - histamine release & cell membrane permeability 19\. Presence of adipose tissue affects the depth of cold penetration - insulator \*\#17 above. Would you perform an intervention (tx) that challenges pt's muscle force generation after cold was applied? Do you wait longer to do 1-RM exercise after cold modality vs heat modality? Note, when you compare the effect of ice and heat modality- it takes longer to return to baseline temperature after cold modality than heat modality. (It takes longer to warm up after ice than cool down after heat.) ------------------------------------------------------- **Effects of Cold on Peripheral Nerves- see Box 2.3** ------------------------------------------------------- 1. Increases threshold for depolarization -- think it will be stimulated, desensitized 2. Slows nerve conduction velocity 3. Extreme cold can block nerve conduction **Note:** The fibers least sensitive to cold were small-diameter unmyelinated fibers such as \_\_\_\_fibers. Cooling to 53.6°F (12°C) blocked conduction in [A] fibers, while considerably lower temperatures were required to block [C-fiber] conduction. Think C fibers are too "hot", very stubborn, to be cooled off. - If we use ice/CP, we can reduce the impulse from A-delta fibers (aka pain). BUT More importantly, sensory nerves cannot be selectively cooled. If you cool off one area, then you will be cooling off everything (including motor nerves). Reduced motor ability should be considered if your patient will be doing tx AFTER the application of cold modality. Interesting but rare cases -- young athletes experienced neurapraxia (n= 3) and axonotmesis (n=1) ------------------------------------------- **Effects of cold on Muscle Performance** -------------------------------------------  1. ↓ ability of a muscle to general tension After cold immersion of healthy legs for [30 minutes] at 50°F to 53.6°F (10°C to 12°C), Oliver et al found that muscle temperature and plantarflexion strength decreased. [At 45 minutes postimmersion], plantarflexion strength began to increase over pretreatment values and continued to do so for the next 3 hours. - Cold can alter muscle force generation, strength assessments on patients during initial and follow-up examinations should be done prior to or several hours after cold modality is used. (be consistent with time -- when to do MMT before/after icing) - Because muscle performance is negatively affected with [cooling for 10 minutes or longer], caution should be taken if strenuous exercise or athletic activities are to be performed after muscular cooling - Any examination or intervention that challenges balance, proprioception, accuracy, or agility should be avoided for a period of time after the application of a cold modality due to the reduction in somatosensory input that these tasks require. ------------------------------------------- **Clinical indications for cold therapy** ------------------------------------------- 1\. **Spasticity** - for local treatments only - the rest of body should be warm. Spasticity: increased resistance to passive stretch; in increase in deep tendon reflexes (DTR) [spastic gait](spastic%20gait) Clonus: spasmodic alteration of contractions between antagonistic muscle groups because of a hyperactive stretch reflex from an Upper Motor Neuron lesion. [Ankle clonus](Ankle%20clonus) 2\. **Early acute (1st 12-24 hrs) injury or inflammation** (contusions, sprains, strains, spasm, etc). Use in conjunction with elevation ([PRICES -- protection, rest, ice, compression, elevation, stabilization)] **Table 2.5** 3. **Pain and Muscle spasms** - (break up pain-spasm-pain cycle) ROM *may* ↑ if pain is reduced; cold is a counterirritant and may lessen pain sensation by stimulating thermal receptors. Analgesia is a direct effect of therapeutic cold. **Quiz**: Cooling the skin can elevate an individual's pain threshold and reduce pain. True or False? **Quiz**: Cold acts as a counterirritant and stimulation of thermal receptors in the skin ([A-delta nerve fibers]) may override pain signals from [C fibers.] 4. Myofascial pain syndrome = "the sensory, motor, and autonomic symptoms caused by myofascial trigger points." Trigger points are thought to be present in skin, ligaments, and fascia. 5. **Migraines?** Despite this relatively widespread application for migraine treatment, there is relatively little evidence supporting the effectiveness of cold therapy. "a gel cap over the head to administer a cold, with participants wearing the cap for 25 minutes. The intervention was effective at decreasing reports of pain, suggesting that cold therapy alone can improve migraine symptoms." (p.40) 6. **Minor burns (sunburn)** 7. **Edema - acute** = first 12-24 hours (Michlovitz: Ch2) Use with elevation. Cold application in combination with compression is more effective than compression alone for the management of edema. 8. **Hyperthermia** - ↑ body temp 2° fever or overexertion ---------------------------------------------------------- **Clinical contraindication for cold therapy Table 2.7** ----------------------------------------------------------  1. Cold intolerance ("I don't like cold") 2. Cold urticaria (ur-tih-KAR-e-uh) -- (hives Fig. 2.15) a. Local response: welts (raised, reddened areas). b. Systemic response: Facial flushing, drop in BP, increase in HR and syncope. The welts are produced by a rapid release of histamine brought about by IgE antibodies and a type of white blood cell (Eosinophil- often involved in allergic reactions) in response to the cold. Rapid cooling, as from the evaporation when one gets out of a swimming pool, can trigger cold urticaria even on a warm day. [For people with cold urticaria, swimming in very cold water is quite dangerous, sometimes even causing death.] 3. Raynaud's Phenomenon= decreased blood supply to distal extremities secondary spasms of arterial smooth muscle- exhibit cycles of pallor, cyanosis, rubor and normal color in hands and feet in response to cold. 4. Paroxysmal cold hemoglobinuria- also known as [Donath-Landsteiner syndrome], is a disease of humans that is characterized by the sudden presence of hemoglobin in the urine (called hemoglobinuria), typically after exposure to cold temperatures 5. Cryoglobulinemia (kry-o-glob-u-lih-NEE-me-uh) - a medical condition in which the blood contains large amounts of cryoglobulins -- proteins (mostly immunoglobulins themselves) that become insoluble at reduced temperatures. 6. Over [a regenerating peripheral nerve] 7. Over [an area of circulatory compromise] 8. Over [an area of peripheral vascular disease] **Quiz**: If the patient had a PVD in B feet, can we apply ice on either UE? **Precautions: (cont table 2-7, p 43) ["Proceed with caution!"]** 1. HTN - monitor B/P throughout if pt is hypertensive. Why? 2. Thermoregulatory disorders why? - esp elderly. ↓vasoconstriction & ↓ shivering → decreased ability to conserve or produce heat 3. Over a superficial peripheral nerve. Why? 4. Over an open wound. Why? 5. Over an area of poor sensation. Why? 6. With individuals with poor cognition. Why? 7. In very young or very old. Why? 8. Persons with aversion to cold. Why? ------------------------------------------------------------------------------------------------------------------------------------- **Effects of Prolonged Exposure to Cold (Adverse Effects)** Systemic response - when local tissues were exposed to cold too long... ------------------------------------------------------------------------------------------------------------------------------------- 1. **[Prolonged]** **[cold]** can [↑] mm tone as the body shivers to produce heat, can increase spasticity [\*Note, if the cold is used appropriately, it can ↓ spasticity by ↓ muscle spindles activity] 2. [Hunting Response/Lewis Reaction/Hunting Reaction of Lewis]: "Cold-induced vasodilation following the initial period of vasoconstriction, resulting in cyclic periods of vasodilation and vasoconstriction and in cyclic warming and cooling of the skin of the face, hands, fingers, feet, and toes." A protective reaction that is normal. However, it can become a problem if it is a continuous response. 3. Decrease in tissue temperature to 10° C (50°F) or below may result in thermal damage to tissues. Thermal damage may trigger an inflammatory response and result in an increase in edema. -------------------- **Contrast Baths** --------------------  **Contrast Baths: (p.155 Michlovitz)** - Distal extremities are alternately immersed in both warm and cold baths. - Alternating between heat and cold water is thought to trigger a vascular pumping action caused by dilation and construction of the vessels. -\> [in theory,] stimulate blood flow and promote healing. - Little evidence supporting this theory - stimulation of the local circulation (ie. R foot) and, to a lesser extent, increased circulation in the opposite untreated extremity (ie. L foot). - Typical **Heat : Cold baths ratios = 3-4 min : 1 min** (longer in the warm bath and shorter in cold water) - Any adverse effects of both heat & cold are less likely to occur when both heat and cold are used. - Sensations experienced by the patient usually appear in 7-15 min (cold, burning, aching, numbness) Indications: ([more research is needed]**)** - Impaired venous circulation - Sub-acute and chronic inflammatory conditions - Chronic Edema - Sinus HA= applied to hands/feet & blood is shunted from the head to the periphery? - DOMS: A few studies reported improved recovery of isometric force and dynamic power and a reduction in localized edema. (after LE exercises) Contraindications: - Same as with superficial heat and cold - Circulatory compromise. - cold temps may cause vasospasm & ↓ circulation (worsens arterial insufficiency) - FYI: difference between Venous and Arterial Leg Ulcers. Precautions: - Insensate skin - Elderly and very young (\< 4 yo) 2° unreliable thermoregulatory systems Procedure: - Check skin as with other modalities - Have the patient go to the bathroom. - Prepare 2 containers of water, thermometer, towels - Warm bath: 38-43° C (100-110° F), Cold bath: 13-18° C (55-65° F) - Repeat until **Rx time is 20 - 30 min example: (4minHOT+1minCold) x 4-cycle= 20mins** - Tx may end in either warm or cold bath - warm for comfort. - Dry the area & follow with assessments, exercise. - While the pt is in 1 bath, you may need to replace the water in the other to keep the water temp constant. **Documentation of Superficial Cold and Heat Modalities** Thorough documentation is needed including modality/method used; temperature of water; durations of heat/cold phases, area treated; patient position; start/stop sequence; patient response during and following treatment. If you see below (compared to baseline skin check) -\> Indicate areas of cold injury. If they appear, rewarm the area, document the occurrence and file an incident report as appropriate for your facility.