Thermal Agents Student Copy PDF

Thermal Agents Adapted from: Joseph Signorino, PT, DPT  Objectives Discuss the various modes of heat transfer Discuss the physiological effects of superficial heating and cooling physical agents Describe the clinical indications, contraindications and precautions for...

Thermal Agents Adapted from: Joseph Signorino, PT, DPT  Objectives Discuss the various modes of heat transfer Discuss the physiological effects of superficial heating and cooling physical agents Describe the clinical indications, contraindications and precautions for superficial heating and cooling physical agents Discuss clinical application of thermal modalities  Remember… Think about how can these modalities be adjunctive to your primary interventions to enhance the clinical outcome?! http://www.techlicious.com/tip/3-smart-ways-to-remember-tasks/  Hot Tubs Should a person with high blood pressure and/or cardiac issues enter a hot tub/sauna? Why or why not? http://getyourmoveonllc.com/how-to-move-a-hot-tub/  Modes of Heat Transfer Conduction Convection Conversion Radiation Evaporation http://www.polytechnichub.com/wp-content/uploads/ 2015/03/modes-of-heat-transfer.jpg  Conduction Result of energy exchange due to collision of two molecules at different temperatures – Faster moving molecules = increased temperature – When speed of the molecules equal, temperature equal between the two materials Heat can transfer to or from the patient (heat v. cold pack), but must be in direct contact Area of contact x Thermal conductivity x Rate of transfer = Temp difference Tissue thickness  Conduction Safety 6-8 layers of towels between the hot pack and the patient are required to limit the TRANSFER of HEAT and minimize burn risk  Thermal conductivity Higher the number, the faster the rate of heat transfer **Silver** 1.01 Aluminum 0.50 Ice 0.005 Water (20 deg C) 0.0014 Bone 0.0011 Muscle 0.0011 Fat 0.0005 Air (0 deg C) 0.000057  Convection Heat transfer resulting from direct contact between a circulating medium and another material of a different temperature More heat transfer over time as compared to conduction, when the same initial temperature is maintained Blood – circulation transfers heat to reduce local changes in tissue temperature Examples: whirlpool, fluidotherapy https://www.ncmedical.com/item_32.html#!prettyPhoto[pp_gal]/2/  Conversion Conversion of nonthermal form of energy (mechanical, electrical, chemical) into heat Not affected by the temp of the thermal agent Dependent on the power of the energy source ○ Device needs to be plugged-in Examples: Ultrasound, diathermy http://www.romochiropractic.com/diathermy-autotherm.html  Radiation Heat (ie thermal) transfers directly from the higher temp to the lower temp, but… Does not require a medium or contact ○ This is why radiation is different from convection and conduction Rate of temp change depends on: ○ Intensity of radiation ○ Relative sizes of radiation source and treatment area ○ Distance between the source and treatment area ○ Angle of radiation to the tissue Example: infrared lamp http://altered-states.net/barry/update343/helio_therapy.jpg  Evaporation A material must absorb energy to evaporate ○ Needs to change from a liquid to a gas Energy absorbed in the form of heat, resulting in a decrease in temp Example: vasocoolant spray, (sweating) http://i.huffpost.com/gen/1282490/images/o- SWEAT-BODYWEIGHT-facebook.jpg http://www.sweatology.net/wp-content/uploads/armpit-sweat2.jpg  Body Core Temperature Normal Body Temp: ○ 37° C +/- 1°C (oral) ○ 98.6°F +/- 1°F (oral) Hyperthermia ○ >99.5°-100.9° F (37.5°-38.3° C) ○ Skin blood vessels dilate to release heat ○ Sweat will evaporate and cool body Hypothermia https://images-na.ssl-images- ○ 20 minutes after exposure – Inconsistent How long should we recommend cryotherapy treatment based on this information? Less than 20 minutes  Neuromuscular Decreased nerve conduction velocity ○ Primarily affects small, myelinated fibers (A-delta) ○ The longer the cooling, the greater the time required for normalizing return to normal function Increased pain threshold ○ Increases pain threshold ○ Decreased temperature may block transmission of painful stimuli to the brain by the process called gating ○ Disruption of pain-spasm-pain cycle ○ Reduction in edema can decrease compression  Neuromuscular Altered strength ○ Can increase or decrease output ○ < 5 minutes ice massage: facilitation of motor neurons, excitability (Increased Strength) ○ > 30 minutes: decreased nerve conduction velocity decreased blood flow increased viscosity increased stiffness ○ Consider timing of MMT (ie ice after MMT performance) Decreased spasticity temporarily ○ Decrease in gamma motor neuron activity (immediate) ○ Afferent spindle and GTO activity decreases (10-30min)  Metabolic Effects Decreased rate of all metabolic reactions ○ Used to control acute inflammation Decreased histamine and prostaglandins levels Decreased joint temp associated with decreased activity of collagen degrading enzymes ○ Associated with OA or RA http://www.food.com/recipe/ice-cubes-524197  Uses of Cryotherapy Inflammation control Edema control Pain control Modification of spasticity MS symptom management Muscle Facilitation https://www.amazon.com/Foam-Leg-Pillow-Elevator-Beige/dp/B000MWED9U  Cryotherapy Contraindications Cold hypersensitivity (cold-induced urticaria- could break out into hives, could lead to shock Cold intolerance Cryoglobulinemia ○ Disorder with serum proteins in the distal circulation when the distal extremities are cooled; these proteins decrease blood flow influencing ischemia Paroxysmal cold hemoglobinuria ○ Condition in which hemoglobin from lysed red blood cells is released into the urine in response to local or general cold Raynaud’s disease ○ Rare disorder of blood vessels in fingers and toes Over regenerating peripheral nerves ○ Ice should not be placed over regenerating nerve because local vasoconstriction or altered nerve conduction may delay nerve regeneration Over an area of circulatory compromise  Raynaud’s Phenomenon http://dermaamin.com/site/atlas-of-dermatology/17-r/1050- raynauds-phenomenon-.html http://laurenbeatssugar.blogspot.com/ 2012/01/raynauds-phenomenon.html  Cryotherapy Precautions Over the superficial main branch of a nerve Over open wounds Hypertension ○ cold can temporarily increase systolic/diastolic pressure. Need to monitor if BP increases Impaired sensation/cognition Very young or patients with cognitive or communication deficits Sensitivity to cold With all variables need to close monitoring http://www.mayoclinic.org/diseases-conditions/foot- drop/multimedia/peroneal-nerve/img-20008172  Cryotherapy Potential Adverse Effects Ischemia Thrombosis of smaller vessels Permanent nerve damage Vasodilation  Clinical Considerations Patient expectations Goal of treatment: “Why is the intervention being provided?” Symptoms pre, during, post  Stages of Cold Response 1.Intense cold 2.Burning 3.Aching 4.Analgesia 5.Numbness Educate your patients on what to expect!  Application Options Cold/ice packs Ice massage Cold compression unit Vapocoolant spray http://www.pain-relief.com/mabis-koolpress- neck-contour-reusable-gel-compress-ice- packs.html http://www.tigerlilystudios.com/spray- stretch-dvd.php http://backtofunction.com/cold-vs- http:// heat-therapy-use-injuries/ www.gameready.com/  Cold Packs/Ice Packs PROS CONS Easy to use Difficult to visualize Inexpensive underlying tissue Not labor intensive Pack weight may be Low level of skill excessive required Difficult to contour Covers mod/large areas to small areas Can be applied on elevated limb Long duration http://www.amdmedsupply.com/index.php/ products/personal-care/cold-therapy/kool- press-ice-pack-11x21.html  Cold Pack Application 1. Expose area; remove jewelry. Inspect skin. 2. Collect pre-intervention NPRS, measure, etc. 3. Wrap cold pack in towel/pillow case. 4. Properly position the patient. Consider elevation for edema management. 5. Place cold pack on problem area and secure with strap, if needed. 6. Treatment time: 10-20 mins to control pain, inflammation or edema. I. If additional towel layers are needed for patient comfort, then treatment time can increase 7. Remove cold pack. Re-inspect skin. Collect post-intervention outcome.  Ice Massage PROS CONS Can observe tx site Time consuming for **Can be applied at large areas small/irregular areas Requires active Short duration participation by Inexpensive therapist throughout Can be applied to elevated limb https://www.youtube.com/watch?v=bBt8xVPzbE4 https:// walkwellstaywell.wordpress.co m/tag/ice-massage/  Ice Massage Application 1. Expose area; remove jewelry. Inspect skin. 2. Collect pre-intervention NPRS, measure, etc. 3. Place towels around treated area to absorb water drippings. 4. Rub ice over the treatment area using small, overlapping circles. 5. Continue ice massage application 5-10mins, or until analgesia is achieved. 6. Remove ice. Re-inspect skin. Collect post-intervention outcome.  Cold Compression/ Vasopneumatic Device PROS CONS Simultaneous cold Difficult to visualize and compression site Well controlled temp Expensive (~$2500; and force $250/wk for rent) *Can be applied to large joints Patient’s often enjoy ☺ http://www.gameready.com/rehabilitation-equipment  Cold Compression Application 1. Expose area; remove jewelry. Inspect skin. 2. Collect pre-intervention NPRS, measure, etc. 3. Cover treated area with sleeve. 4. Ice temperature should range from 50-59F 5. Turn on machine or place in proper position for water flow. 6. Apply x 15-20mins. 7. Remove sleeve. Re-inspect skin. Collect post- intervention outcome.  Vapocoolant Spray PROS CONS Brief duration Limited to use for brief, Localized areas of localized, superficial application application of cold before stretching Could you use this before or after dry needling? No, you don’t want to risk http://www.priorityhealthsupplies.com/ infection Gebauer-s-Spray-and-Stretch-Fine- Stream-p/gebss1.htm Thermal Applications of Heat  Thermotherapy Can be used medically to burn off tissue Therapeutically used for improved function, decreased pain http://www.hotcoldcomfort.com/collections/bulk-wholesale-heat-pads  Thermotherapy Effects Hemodynamic - vasodilation Neuromuscular Metabolic Altered tissue extensibility http://biology-forums.com/index.php?action=gallery;sa=view;id=13264  Hemodynamic Effects Vasodilation (local and distant areas) Sympathetically mediated smooth muscle relaxation Example: Pressure ulcer  Neuromuscular Effects Increased nerve conduction velocity (NCV) ○ Decrease conduction latency of sensory and motor nerves ○ Increase NCV by 2 m/s for each 1deg C increase Firing rate changes Decrease rate of type II muscle spindle efferents and gamma efferents, AND… Increase firing rate of type 1b from GTO This means a decrease firing in the rate of alpha motor neurons → decreased muscle spasm  Neuromuscular Effects – Increased pain threshold Activate spinal gating mechanism in spinal cord Prevention of ischemia via vasodilation – Changes in muscle strength – Potentially decreased during first 30 min post tx – Due to change in firing rate in type II muscles resulting in decrease in firing of alpha motor neurons – Implications for MMT? Take MMT Before  Metabolic Effects Increases rate of endothermic reactions → increased rate of cellular biochemical reactions Beyond 113 deg F, enzyme activity decreases because too hot! Caution: can increase collagenase activity which will destruct articular cartilage ○ Avoid use in active inflammatory disease processes  Altered Tissue Extensibility Increased tissue temp increases collagen extensibility Associated with improved mobility following stretching as compared to stretching alone  Thermotherapy Indications Pain control But…not for acute inflammation Increasing ROM and decreasing joint stiffness Accelerated healing Infrared radiation (ultraviolet) for psoriasis  Thermotherapy Contraindications Recent or potential hemorrhage ○ Heat encourages vasodilation; weak vessels can burst Thrombophlebitis ○ Vasodilation can encourage thrombus to break off and influence CVA or PE Impaired sensation/mentation ○ Possible for burns Malignant tumor ○ Vasodilation resulting from heat may increase cancer growth rate No treatment over the eyes ○ Gelatinous center  Thermotherapy Precautions Acute injury or inflammation (Avoid first 48-72 hrs) Pregnancy Impaired circulation Poor thermoregulation ○ Very young, very old Edema Cardiac insufficiency Metal in the area Over an open wound http://www.idacontrol.com/support.php?nid=27 Over topical counterirritants Demyelinated nerves  Potential Adverse Effects Burns* Fainting https://agentkdotorg.wordpress.com/2014/10/15/integumentary-system/ Bleeding Skin/eye damage http://articles.latimes.com/2012/aug/07/news/la-heb-fainting-spells-genetic-basis-20120807  Application Options Hot packs Paraffin Contrast bath http://www.imeq.us/2014/04/effectiveness-of-infrared- medical-lamps.html Infrared lamps https:// www.ncmedical.com/ item_32.html#! prettyPhoto[pp_gal]/2/ Fluidotherapy http://www.imeq.us/2014/04/effectiveness-of-infrared- http://www.therabathpro.com/about_paraffin_new.php medical-lamps.html  Hot Packs PROS CONS Easy to use Cannot visualize tissue Inexpensive materials Weight can be heavy Brief clinical time Difficult to contour small/bony areas Low level of skill Patient typically passive necessary throughout Generally safe Can become expensive Can be used at home Electrical Heat – NEVER Can cover large areas cools  Hot Packs http://www.lindept.com/hot%20cold%20therapy.htm  Moist Heat Application 1. Expose area; remove jewelry. Inspect skin. 2. Collect pre-intervention NPRS, measure, etc. 3. Wrap the hot pack in 6-8 layers of dry towels. I. Hot pack cover can substitute for two towel layers II. Be cautious to prematurely remove towel from layers based on the patient’s initial complaint of not feeling heat. Instruct to allow time for towels to warm and transmit heat. If after several minutes the complaint remains, towels can be removed and the patient monitored. 4. Apply heat pack x 20mins. Secure pack to patient, if needed. 5. Check the skin after 5 mins of application to assess for burns. 6. Remove moist heat pack. Re-inspect skin. Collect post-intervention outcome.  Paraffin Bath PROS CONS **Good contact with Messy, can be time bony/small areas consuming to apply ○ Hands, feet Cannot be used Easy to use over open lesions Inexpensive Possible cross- Oil lubricates/ contamination conditions the skin Can be used at https://www.sharperimage.com/si/view/product/ Paraffin+Bath+Treatment/200998 home  Paraffin Application 1. Expose area; remove jewelry. Inspect skin. 2. Wash hands, feet or treated area. 3. Collect pre-intervention NPRS, measure, etc. 4. With the fingers apart, dip the hand into paraffin as far as possible and remove. Minimize movement to avoid cracking. I. Instruct the patient to avoid touching the side and bottom of the paraffin bath as it is hot 5. With hand removed from wax, wait until wax become opaque 6. Redip the hand keeping fingers apart. Repeat 3-5 times. 7. Wrap the patient’s hand in a plastic bag and then in a towel or oven mitt. 8. Comfortably position the patient. Apply 10-15mins 9. Remove wax and discard (can reuse if personal use at home). Re-inspect skin. Collect post- intervention outcome.  Contrast Bath PROS CONS Can stimulate Limb in dependent circulatory system position Good contact of Difficult to tolerate contoured areas Questionable Can provide pain evidence control without aggravating edema Allows movement https://www.youtube.com/watch?v=RwM2LrN1L5w https://www.youtube.com/watch?v=RwM2LrN1L5w  Contrast Baths 1. Expose area; remove jewelry. Inspect skin. 2. Collect pre-intervention NPRS, measure, etc. 3. Fill two containers as follows: ○ Warm water at 100◦-111◦F ○ Cold/cool water 50◦-64◦F 4. Immerse treated area in warm water for 3-10 mins and then the cold water for 1-3mins. 5. Repeat sequencing 5-6 times to provide a total treatment time of 25- 30 mins. 6. Remove from water. Re-inspect skin. Collect post-intervention outcome.  Fluidotherapy CONS PROS Patient can move Expensive during intervention Possible for edema Minimal pressure on area being to worsen treated May cause Temp well overheating controlled and Corn cob particles constant Easy to administer are hard to clean up Noisy  Fluidotherapy https://www.sharperimage.com/si/view/product/ Paraffin+Bath+Treatment/200998  Infrared Lamps PROS CONS No medium needed Not easy to localize No contact needed, treatment so decrease risk of Difficult to ensure infection consistent heating Can observe http://www.spaandequipment.com/ treatment area Salon-Spa-Infrared-Lamp.html throughout  Documentation Area of the body treated Type of cooling or thermal agent integrated Treatment duration Patient positioning *Response to the intervention ○ Pain ○ Edema via circumferential measure ○ Etc. http://www.jobrouter.com/ document ○ Visual Inspection: “Skin was visually inspected following modality and intact skin observed. No adverse events observed.”  Think about… Stage of healing ○ Ice v. heat? ○ Length of time? (immediate post-op v. acute v. chronic) Goal of treatment ○ Edema control? ○ Pain control? Etc. Order of treatment ○ Heat before cold OR cold before heat? WHY? Patient position ○ Comfort ○ Tissue extensibility  Very Common Clinical Question Shoulder I use heat or ice? https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQVf7c5iNNJV3FCxGR2moK- https://static.toiimg.com/photo/58378816.cms  Let’s go practice! To the lab!