W1 PPT- Modalities- Intro, Cryotherapy and Thermotherapy PDF

4/19/2024 1 Modalities (PTA 1009)- PowerPoint #1 Intro, Cryotherapy and Thermotherapy ©Stanbridge University 2024 1 ...

4/19/2024 1 Modalities (PTA 1009)- PowerPoint #1 Intro, Cryotherapy and Thermotherapy ©Stanbridge University 2024 1  4/19/2024 2 ©Stanbridge University 2024 Introduction to Modalities Learning Objectives At the completion of this lecture, you will be able to: Define physical agents and therapeutic modalities The difference between acute vs chronic pain Understand the basic pathways of pain Describe the gate control theory Understand the roles that therapeutic modalities play in physical therapy rehabilitation Patient assessment methods Identify different types of commonly used modalities in the clinic Identify the clinical application of modalities Discuss the efficacy of modalities Identify the most common general contraindications and precautions for use of modalities 2  4/19/2024 3 ©Stanbridge University 2024 Nomenclature: Physical Agent vs. Therapeutic Modality Some clinicians use these terms interchangeably, but they are NOT the same Knowing the difference makes a difference in the care you provide ▫ Physical Agents: refer to the use of physical energies such as thermal, mechanical, electromagnetic or light but fails to include the purpose or intention of their use ▫ Therapeutic Modality: refers to the use of a physical agent for a specific therapeutic effect (i.e. decrease pain, increase ROM, improve tissue healing, improve muscle recruitment) Using correct nomenclature leads to better documentation Better documentation leads to better reimbursement 3  4/19/2024 4 ©Stanbridge University 2024 Role of Therapeutic Modalities in Rehabilitation The role of therapeutic modalities in clinical practice is to complement other elements of the more comprehensive therapy plan (i.e., ther ex, manual therapy, patient education). Manual Therapy Therapeutic Patient Modalities Education Ther ex Source: www.rbkc.gov.uk 4  4/19/2024 5 ©Stanbridge University 2024 Role of Therapeutic Modalities in Rehabilitation Examples of modalities in conjunction with other therapeutic interventions: ▫ Cold pack to decrease swelling/pain from an acute injury, or following therapy if symptoms are exacerbated ▫ Ultrasound increase soft tissue elasticity prior to stretching or joint mobilization Commonly used to reduce or overcome factors that hinder continuation of the therapy plan (i.e. pain inhibiting participation in therex, knee effusion inhibiting quadriceps contraction) 5  4/19/2024 6 ©Stanbridge University 2024 Clinical Application of Therapeutic Modalities Modalities are primarily used for: (in conjunction with other interventions) ▫ Modulation of pain ▫ Alteration of skeletal muscle performance ▫ Decrease inflammation ▫ Facilitate tissue healing ▫ Increase tissue extensibility In order to: 1. Restore Prior Level of function (PLOF) 2. Improve the patients’ quality of life 6  4/19/2024 7 ©Stanbridge University 2024 Therapeutic Intervention Clinical Decision Making determines and affects: ▫ The form that the treatment takes ▫ The timing at which it is administered ▫ The attitude of the clinical provider Each of these has a profound affect on the patient’s outcomes, their speed of improvement and their total rehab experience 7  4/19/2024 8 ©Stanbridge University 2024 Pain Pain: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” A patient’s description of what is “painful” is variable based on past or current experiences 8  4/19/2024 9 ©Stanbridge University 2024 Pain Anatomy of Pain Nociceptors (pain receptors) send pain signal Thalamus = distribution of information Anterior cingulate cortex, somatosensory cortex, insular cortex & prefrontal cortex→ Process nociceptive information Brain systems for pain overlap with systems of emotion ▫ Negative experience of pain= amplified pain experience 9  4/19/2024 10 Types of Nociceptors: ©Stanbridge University 2024 High Threshold Mechanoreceptors: Respond to strong mechanics stimulation, A-delta, fast, Sharp “pricking” sensation, well localized Mechanothermal nociceptor: Respond to Strong mechanical stimulation, noxious heat, A delta fiber connection, fast, Sharp “pricking” sensation, well localized Polymodal nociceptor: Responds to strong mechanical stimulation, noxious heat, irritant chemicals, C fiber, slow, Dull, aching, burning and poorly localized 10  4/19/2024 11 ©Stanbridge University 2024 Pain and Neural Fibers A-delta Fibers: myelinated; sharp prickling pain C- Fibers: unmyelinated; dull and poorly localized ▫ A- delta fibers are faster than C fibers ▫ A-delta and C fibers are found in the dorsal root ganglia ▫ Within the dorsal horn the A- delta and C fibers communicate with different types of neurons in different layers of grey matter 11  4/19/2024 12 ©Stanbridge University 2024 Reaction to Pain Systemic reaction- “Fight or flight”-ANS ▫ Increased HR ▫ Sweating ▫ Expansion of bronchioles ▫ Dilation of pupils ▫ Shunting of blood away from skin and digestive tract towards muscles and brain ▫ Decreased peristalsis ▫ Contraction of sphincters 12  4/19/2024 13 ©Stanbridge University 2024 Reaction to Pain Local reaction- Muscle guarding ▫ High level of metabolism in muscle(s) in immediate area ▫ Compression of blood vessels → ischemia  New source of pain  Limited removal of metabolites ▫ Increased edema from injury and increased capillary permeability ▫ Limited nutrient supply = limited healing 13  4/19/2024 14 ©Stanbridge University 2024 Reaction to Pain Vicious cycle ▫ Pain→ Muscle guarding→ Pain→ Muscle guarding→ Pain Endogenous pain substances produced by body ▫ Potassium ▫ Serotonin ▫ Bradykinin ▫ Histamine ▫ Prostaglandins ▫ Leukotrienes ▫ Substance P Source: www.rcemlearning.co.uk 14  4/19/2024 15 ©Stanbridge University 2024 Neurochemistry of Pain Glutamate: transmits pain by binding to a specific channel on the A- delta fibers that transmit the pain signal to the dorsal horn of the spinal cord Source: Hiroshima University https://www.eurekalert.org/pub_releas es/2015-07/hu-nmm071415.php 15  4/19/2024 16 ©Stanbridge University 2024 Diagnosing pain Tests and measures to identify the physical source of pain: Musculoskeletal and Neurological examination Laboratory tests Electrodiagnostic procedures EMG, nerve conduction studies, evoked potential studies, quantitative sensory testing MRI X-ray 16  4/19/2024 17 ©Stanbridge University 2024 Acute vs Chronic Pain Acute pain (Self-limiting) Acute vs Chronic Pain ≠ Acute, subacute, chronic stages of healing ▫ Result of infection, injury, or internal disease ▫ Localized ▫ Easier to treat ▫ Progresses through the 3 phases of tissue healing Chronic pain (Multi-factorial, chronic disease condition) ▫ May or may not relate to an actual physical injury ▫ May not see obvious physical findings ▫ Longer the pain persists- referred further away from the origin ▫ Genes alter protein production which increases excitation of pain receptors in spinal cord and brain 17  4/19/2024 18 ©Stanbridge University 2024 Tissue Healing Phases (subcategories of acute pain) Acute: 0→4-6 days ▫ Inflammatory phase ▫ Cardinal signs of inflammation Subacute: 4-6 days→ 14-21 days ▫ Proliferative phase - revascularization and rebuilding Chronic: > 14-21 days→ 6 months or greater ▫ Remodeling and Maturation phase 18  4/19/2024 19 ©Stanbridge University 2024 Chronic Pain Criteria for classification as chronic pain 1. The cause is uncertain and not easily treatable 2. Medical treatments have been ineffective (unchanging pain) 3. Pain has persisted longer than 3-6 months Maladaptive behavior- pain behavior, depression, negative coping Requires a team approach- psychological support, therapists, social workers, MDs, nurses etc. Empower pt through education 19  4/19/2024 20 ©Stanbridge University 2024 Pain Treatments Therapeutic modalities can modulate the pain without the use of medications Theories have been proposed for how this occurs including ✓ Gait Control Theory ✓ Assistance in release of endogenous opioids ✓ Psychological factors influence pain response and perception 20  4/19/2024 ©Stanbridge University 2024 Gate Control Theory Theory developed in 1965 by Melzack and Wall Selective stimulation of large diameter afferent A-beta sensory fibers block noxious input from C and A-delta pain fibers ▫ Blockage occurs from activation of the substantia gelatinosa (SG) Gate Control Theory- Non-painful input closes the nerve “gates” to painful input, which prevents pain sensations from traveling to the CNS. Non-painful sensations override and reduce painful sensations. ▫ Description to patients: The sensation of touch and the sensation of pain travel in the same pathways to the brain so by adding the sensation of touch then the brain doesn’t feel the pain and the muscles can relax and heal. 21  4/19/2024 ©Stanbridge University 2024 Endogenous Opioid System Activation of the A-delta fibers causes the release of an endogenous opiate (encephalin) in the spinal cord which will reduce the activation of the noxious sensory pathways Neurotransmitter GABA may play a role in further pain inhibition Image Credit: Molecular Arts / Shutterstock 22  4/19/2024 23 ©Stanbridge University 2024 Pain Assessment Pain scales= Subjective report ▫ Visual analog scale (VAS)  change of 28mm (2.8 cm) to be significant ▫ Numeric Pain Rating Scale (NPRS)- 1-10  change of 3 pts needed to be significant ▫ McGill Questionnaire ▫ Anatomical pain drawings ▫ Facial Expression ▫ Pain Assessment Tool Kit pgs 51-52 23  4/19/2024 24 ©Stanbridge University 2024 Subjective Report- pain scales Visual Analog Scale (VAS) Wong-Baker Faces Pain Rating Scale Source: Cameron and Monroe 2011 24  4/19/2024 25 ©Stanbridge University 2024 Therapeutic Modalities Source: Bellew 2016 25  4/19/2024 26 ©Stanbridge University 2024 Types of Therapeutic Modalities Classifications: ▫ Thermal ▫ Electromagnetic ▫ Mechanical Thermal: Heat and Cold (i.e. moist heat pack, ice massage) Electromagnetic: (i.e. electrotherapy, diathermy, ultraviolet and infrared light) Mechanical: (i.e. traction and compression) 26  4/19/2024 27 ©Stanbridge University 2024 Principles of Heat Transfer Conduction- loss or gain of heat from direct contact between 2 materials ▫ High thermal conductivity transfers heat faster than lower thermal conductivity (i.e. Water transfers heat faster than air) ▫ Ex: Hot pack, cold pack, paraffin, ice massage, Cryocuff 27  4/19/2024 28 ©Stanbridge University 2024 Principles of Heat Transfer Convection- Gain or loss of heat resulting from air or water in a constant motion across the body (i.e. blood circulation) ▫ Ex: Fluidotherapy, hot whirlpool, cold whirlpool Conversion- Non-thermal energy is absorbed into the tissue and transformed to heat ▫ The rate of transfer is determined by the power of the energy source ▫ Doesn’t require direct contact but does require a medium (gel, water, air) ▫ Ex: Diathermy, Ultrasound 28  4/19/2024 29 ©Stanbridge University 2024 Principles of Heat Transfer Evaporation- Transfer of heat as liquid absorbs energy and transforms into a vapor ▫ Ex:Vapocoolant spray Radiation- Direct transfer of heat from a radiation source of higher temperature ▫ There is no direct contact from the source ▫ Ex: Infrared lamp, Laser, Ultraviolet light 29  4/19/2024 30 ©Stanbridge University 2024 Clinical Application of Therapeutic Modalities If you cannot explain the physiological and clinical reasoning for using the therapeutic modality you select, then you should NOT be using that technique 30  4/19/2024 31 ©Stanbridge University 2024 Assessing Effectiveness of Modalities Therapeutic modalities have been criticized based on their effectiveness on alleviation of pain Study on the efficacy of therapeutic modalities has not shown lack of efficacy but a lack of quality of research performed on therapeutic modalities Assessing modalities separate from other interventions is difficult due to ethics (should we withhold other interventions that will help just to assess efficacy?) Walsh d, Howe T, Johnson M, Sluka k. Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database of Systematic Reviews (2); Art. No.: CD006142. DOI: 10.1002/14651858.CD.006142.pub2.; 2009 31  4/19/2024 32 ©Stanbridge University 2024 Assessing Effectiveness of Modalities Clinical Presentation Measurement Therapeutic Modality Swelling Girth; Circumference; Volumetrics Cryotherapy; Compression Thermotherapy; Diathermy; Decreased ROM; Flexibility Goniometric Measurements Ultrasound Weakness Strength Tests (MMT, Dynamometry) NMES; Biofeedback Functional Outcome Measures (LEFS, DASH, Variable (Cryotherapy, Compression Decreased Functional Ability Oswestry LBI, NDI, TUG, Tinetti, FIM) Thermotherapy, Electrotherapy) Tissue Healing (Closure Time, Wound Compromised Integumentary E-Stim (HVPC) Depth) Variable (Cryotherapy, Thermotherapy, Pain Pain (VAS) Compression, US, Electrotherapy) ROM Poor Posture Thermotherapy Muscle length tests 32  4/19/2024 33 ©Stanbridge University 2024 Using the Right Outcomes Outcome measures need to show functional improvement that is statistically significant to be reimbursed for your skilled services What makes us more likely to conclude that a modality is ineffective when it may be effective? ▫ If we use inappropriate measurements ▫ Match the modality with wrong diagnoses ▫ Match the modality with the wrong stage of healing 33  4/19/2024 34 ©Stanbridge University 2024 Overview of Precautions and Contraindications 34  4/19/2024 35 ©Stanbridge University 2024 Screening It is imperative that a proper screen is conducted before application of any therapeutic modality Screening will ensure that no injury occurs The most likely place for injury to occur and thus legal actions arise is with the application of modalities Screening includes: ✓Checking for contraindications and precautions ✓Proper skin assessment ✓Proper sensation screen 35  4/19/2024 36 ©Stanbridge University 2024 Proper Skin Assessment Always performed bilaterally to compare for the patient norm Skin pigmentation/color changes Visual inspection for open wounds, rashes, etc. Capillary refill: assesses for normal blood flow in the distal extremity Normal is ≤3 secs Blanching: assesses for normal blood flow in the area to be treated Normal is ≤3 secs Skin surface temperature- using back of hands Source: Behrens 2014 36  4/19/2024 37 ©Stanbridge University 2024 Sensation screening Light touch screening- basic assessment in the area to be treated to ensure patient is aware of general sensation in the area ▫ Use very light pressure with one finger, avoid sweeping motion Hot/cold sensation- performed when the modality provides a hot or cold sensation to ensure they can communicate if the modality becomes too hot or too cold ▫ Use one item that is cold (placed in freezer) and one item that is warm ***Perform the screening everywhere the modality will be contacting the skin. 37  4/19/2024 38 ©Stanbridge University 2024 Overview of Precautions and Contraindications Contraindication: Conditions or factors of a patient that make using a specific modality inadvisable. It is against (or contra-) the usual indication to use a specific therapeutic modality. ▫ Example: it is contraindicated to apply therapeutic US over the abdomen of a pregnant woman 38  4/19/2024 39 ©Stanbridge University 2024 Overview of Precautions and Contraindications Precaution: Not outright contraindicated but are factors, conditions or findings presented by a patient that require special consideration. ▫ Example: If a patient has compromised peripheral circulation such as PVD, it is a precaution to use US because excessive temp. elevation may occur due to the body’s inability to dissipate the heat adequately 39  4/19/2024 40 ©Stanbridge University 2024 Overview of Precautions and Contraindications 5 most common contraindications or precautions that practitioners are likely to encounter: ▫ Compromised, impaired, or diminished sensation ▫ Compromised, impaired, or diminished cognition ▫ Electronic implants: pacemakers, cardioverter defibrillators, phrenic nerve stimulators and pain or spasticity pumps ▫ Pregnancy ▫ Presence of cancer (active) 40  4/19/2024 41 ©Stanbridge University 2024 Thermal Modalities: Cryotherapy 41  4/19/2024 42 ©Stanbridge University 2024 Objectives: Cryotherapy By the end of this section the student should be able to describe: Types of Cryotherapy Physical principles of Cryotherapy Physiological responses Indications, contraindications and precautions Advantages and Disadvantages General technique/application, Dosage and Frequency 42  4/19/2024 43 ©Stanbridge University 2024 Cryotherapy Cryotherapy aka “cold therapy” Cryotherapy is the use of cold to induce the therapeutic and physiological responses that result from a decrease in tissue temperature Results in reduced blood flow and tissue metabolism Physiological response: to decrease bleeding and acute inflammation following injury or tissue disruption Reduces pain by desensitizing peripheral afferent (sensory) nociceptors (pain receptors) 43  4/19/2024 44 ©Stanbridge University 2024 Physical Principles of Cryotherapy ▫ Cooling is accomplished by removing or abstracting heat from an object rather than by adding cold ▫ Two Scales to measure temperature:  Celsius = 5/9 (°F - 32)  Fahrenheit = (9/5 x °C) + 32 ▫ Three types of energy transfer:  Conduction  Convection  Evaporation 44  4/19/2024 45 ©Stanbridge University 2024 Cryotherapy modalities Therapeutic cold can be applied in various methods: ▫ Ice packs (gel or crushed ice): commonly used and conform to body ▫ Ice cube/cup: used for ice massage directly to skin ▫ Cold water: cool whirlpool or cold-water bath ▫ Vapocoolant Spray aka “Spray and Stretch”: Flouro-Methane Spray cools by rapid evaporation ▫ Controlled cold compression units 45  4/19/2024 46 ©Stanbridge University 2024 Cryotherapy Depth of penetration: reported up to 1- 4 cm ▫ Adipose tissue will slow penetration due to insulation effects = longer application will be needed ▫ For joints, decreased time needed for cooling Prolonged tissue temp below 50° F will result in thermal damage and increase edema Source: www.commons.Wikimedia.org 46  4/19/2024 47 ©Stanbridge University 2024 Cryotherapy Timing Due to the physical principles and effects of cryotherapy: Cryotherapy is applied at the end of treatment ▫ Exception: quick ice for reduction of spasticity It should not be applied prior to activity or stretching Can be used in all 3 phases of tissue healing ▫ Acute phase is most common to reduce edema, pain ▫ In subacute and chronic phases, it is used preventatively 47  4/19/2024 48 Cryotherapy Indications ©Stanbridge University 2024 Deeper tissues must be cooled for longer periods that superficial tissues, very cold sources must be used less amount of time than cool sources ▫ Spasticity: no lower than 59°F for 20-45 minutes ▫ Muscle guarding or spasm: no lower than 59 ° F, 20-45 minutes ▫ Edema: no lower than 59 ° F; 4-20 minutes ▫ Acute musculoskeletal trauma: 56.5 ° F for 4.5-15 minutes ▫ Pain (acute and chronic): 56.5 ° F for 4.5-15 minutes ▫ Myofascial pain syndrome: 56.5 ° F for 4.5-15 minutes ▫ Emergency care for small burns – immediately cool down the area 48  4/19/2024 49 ©Stanbridge University 2024 Cryotherapy Selection of the appropriate form and method of therapeutic heat will depend on several factors: ▫ Size of the affected area ▫ Depth of the tissues to be treated ▫ Patient’s tolerance to cold ▫ Whether the application will occur in the clinic or at home ▫ Other interventions that are complimented by use of therapeutic cold 49  4/19/2024 50 ©Stanbridge University 2024 Cryotherapy How to select cryotherapy as a cooling agent ▫ Which body area is to be cooled?  Consider the bony architecture/anatomy ▫ How much body surface is to be cooled?  Tendon, bursae, small muscle belly= ice massage  L/S paraspinals, shoulder, elbow = ice pack ▫ Is edema present?  Consider compression and cold therapy 50  4/19/2024 51 ©Stanbridge University 2024 Cryotherapy General Procedure for all Cryotherapy Interventions: ▫ Instruct the patient ▫ Remove jewelry/clothing from area to be cooled ▫ Position the patient comfortably ▫ Drape appropriately ▫ Check sensation (intact or impaired) ▫ Check skin integrity ▫ Remain nearby during treatment ▫ Following the treatment, return equipment to its proper location ▫ Following the intervention, re-examine the patient for their response ▫ Document your findings and document the skin screening performed 51  4/19/2024 52 ©Stanbridge University 2024 Responses to Cryotherapy ✓ Normal sequence with extremely cold sources (occurs within 7-15 minutes) ▫ Cold ▫ Burning ▫ Aching ▫ Numbness ***Ice massage- sequence can occur within 5 minutes ✓ Abnormal responses indicating cold injury ▫ Excessive redness ▫ Swelling ▫ Areas of pallor Tx for abnormal responses: re-warm the area rapidly, document the occurrence, file incident report. 52  4/19/2024 53 ©Stanbridge University 2024 Cold Pack (Lab) Cold pack should be cooled 30 minutes between uses Protective layer between cold pack and skin (pillow case) Time: 20 minutes at most for commercial pack Depth of penetration: 2 cm Frequency: every 1-2 hours maximally Source: Bellew 2016 53  4/19/2024 54 ©Stanbridge University 2024 Ice Massage (Lab) Uses Decrease edema/inflammation ▫ Cover an area 10-15 cm in ~5 min; 10-15 minutes for muscle belly ▫ Continue until anesthesia (CBAN) Facilitate motor responses (“quick icing”) ▫ Stroke from insertion to origin 3-5 secs over muscle belly x 3 reps ▫ Repeat 3-5 sets if necessary. ▫ The quick application does not produce the other cooling effects like other uses of cryotherapy 54  4/19/2024 55 ©Stanbridge University 2024 Cold Bath Allows for circumferential contact with the cooling agent Water temperature 55-64° F Duration 15-20 min https://trainingparadise.com/icebath-exercise-recovery/ 55  4/19/2024 56 ©Stanbridge University 2024 Vapocoolant Spray Provides rapid cooling through evaporation Most used for trigger point relief Counter-irritant stimulus →reduction in motor neuron activity + decrease in resistance to stretch gebauer.com 30° angle; 12-18 inches from the skin Cover face and spray one direction only Youtube.com 56  4/19/2024 57 ©Stanbridge University 2024 Biofreeze coolant gel Chemical irritant Decreases pain via the gate control theory and (thermosensitive neuron) receptor stimulation Vasoconstriction occurs in the ipsilateral and contralateral limb x 5-10’ (min) after use Don gloves for application- perform gentle stroking (massage) into the tissue- only to the point of it being “soaked” into the skin Avoid deep STM (potential discomfort with cold/ burning sensation) Do NOT use heat treatment after application Allows for patient movement while it works Caution when applying before exercise- once sweating the biofreeze will travel where the sweat does…. Source: www.protherapysupplies.com 57  4/19/2024 58 ©Stanbridge University 2024 Controlled Compression Unit Circulates cold water through a sleeve Water temp 50-77° F Pressure 0-75mmHg; 30mmHg most common Treatment time: 30’ on/30’ off Often provided post-operatively (after peripheral joint surgery Source: Bellew 2016 58  4/19/2024 59 ©Stanbridge University 2024 Cryotherapy- Evidence A Evidence for use of cryotherapy to decrease postoperative knee pain immediately post ACL reconstruction and intermittently after ankle sprains to decrease need for pain medications and improve weight bearing Knee Ligament Sprain: Clinical Practice Guidelines, JOSPT 2010; 40(4):a1-a37 Ankle Ligament Sprain: Clinical Practice Guidelines, JOSPT 2013; 43(9): a1-a40 -Acute phase ice reduces tissue metabolism→ reduces hypoxic injury, cell debris, and edema 59  4/19/2024 60 ©Stanbridge University 2024 Cryotherapy Evidence I Bleakley et al., The use of ice in the treatment of acute soft-tissue injury, a systematic review of randomized control trials; The Am J of Sports Med, 2004; 32(1):251-261 -In subacute phase - most effective when used with exercise -Reduces pain, spasm and neural inhibition→ earlier aggressive exercise 60  4/19/2024 61 ©Stanbridge University 2024 Cryotherapy (Cold Therapy) Contraindications for Cryotherapy: ▫ Patients with cardiac dysfunction (i.e. angina pectoris) ▫ Open wounds ▫ Arterial insufficiency (atherosclerosis, Raynaud’s disease, PVD) ▫ Cold Uticaria (hives) ▫ Patients with pre-existing anesthetic skin ▫ Patients that are unable to communicate ▫ Regenerating peripheral nerves 61  4/19/2024 62 ©Stanbridge University 2024 Cryotherapy (Cold Therapy) Precautions for Cryotherapy: ▫ Extremes of age ▫ Hypertension ▫ Thermoregulatory disorders ▫ Over an area with poor sensation ▫ Patients with poor cognition ▫ Persons with an aversion to cold ▫ Over superficial peripheral nerves w/minimal subcutaneous fat ▫ Patients with hypersensitivity to ice *** Proprioception and throwing accuracy are diminished following 20 minutes of ice. Joint stability may be affected therefore athletes should avoid returning to play/practice immediately after icing. 62  4/19/2024 63 ©Stanbridge University 2024 Cryotherapy (Cold Therapy) Assessment and Effectiveness of cryotherapy can be achieved by using the following outcome measures: ▫ Edema: girth measurements, volumetrics ▫ Pain: quantification via pain scales (VAS) or questionnaires ▫ Functional movements: observe gait quality or ease of active ROM ▫ Muscle guarding: goniometric measures and muscle flexibility measures 63  4/19/2024 64 ©Stanbridge University 2024 Cryotherapy (Cold Therapy) Documentation should include: ▫ Skin screening performed (if first time receiving modality) ▫ Type of cold agent ▫ Treatment duration ▫ Site of cold application ▫ Position of patient for cold application ▫ Use of concurrent compression or elevation ▫ Change in skin appearance ▫ Objective and subjective patient response ▫ Adverse responses 64  4/19/2024 ©Stanbridge University 2024 Thermal Modalities: Heat Photo by Dr. Rikesh Hirani PT, DPT, OCS 65  4/19/2024 ©Stanbridge University 2024 Objectives By the end of this section the student should be able to describe: Types of therapeutic heat Physical principles of thermotherapy Physiological responses Indications, contraindications and precautions Advantages and Disadvantages General technique/application, dosage and frequency 66  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Thermotherapy: “Thermo”= heat Application of heat may facilitate tissue healing, relax skeletal muscles, decrease spasms, decrease pain, increase blood flow Heat also prepares joints, muscles and other soft tissues for stretching, mobilization and exercise Heat can be applied in many forms and by many methods: ▫ Warm water as used in a bath or whirlpool ▫ Moist heat packs, commercial heat wraps ▫ Ultrasound ▫ Diathermy ▫ Ultraviolet or Infrared light 67  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Physical principles of heating tissue are: ▫ Convection ▫ Conduction ▫ Radiation ▫ Conversion Heat transfer is accomplished through these four primary processes Thermal conductivity: materials with high thermal conductivity transfer heat faster, i.e. metal faster than plastic 68  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) The extent of heat exchange depends on: 1. The temperature difference between agent and tissue 2. The time of exposure to the agent 3. Thermal conductivity of the exposed tissue 4. Intensity of the thermal agent 69  4/19/2024 70 ©Stanbridge University 2024 Thermal Modalities: Heat Selection of the appropriate form and method of therapeutic heat will depend on several factors: ▫ Area to be treated ▫ Depth of the tissues to be heated ▫ Patient’s tolerance to heat ▫ Patient’s medical history ▫ Other interventions being used that are complimented by therapeutic heat 70  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Heat modalities using Conversion include: ▫ Ultrasound ▫ Short wave diathermy ▫ Extracorporeal shockwave therapy *These will be covered in detail in future weeks 71  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Conductive heat modalities Radiation: ▫ Moist hot packs ▫ Infrared heating lamp ▫ Paraffin wax ▫ LASER- High level laser therapy ▫ Electric heating pads (dry heat) (HILT) ▫ Air-activated, wearable heat wraps Convective heat modalities include: ▫ Fluidotherapy (fluidized therapy) ▫ Hot/Warm Whirlpool https://www.machinedesign.com/learning- resources/whats-the-difference- between/document/21834474/whats-the- difference-between-conduction-convection-and- radiation 72  4/19/2024 ©Stanbridge University 2024 Depth of Thermotherapy (Heat Therapy) Superficial Deep ▫ Hot packs (158-167° F) ▫ Continuous ultrasound ▫ Air activated heat wraps (104°F) ▫ Continuous shortwave diathermy ▫ Warm whirlpool (96-104°F) ▫ Fluidotherapy (102-118°F) ▫ Paraffin (113-122°F) Treat to depths of 3-5 cm Affect more of the skin and the subcutaneous tissue Affects tissue up to 2 cm 73  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Superficial heating agents ▫ Do NOT allow for increases in muscle temperatures unless the muscles are superficial or the agent is left on for 15-30 minutes or longer All structures in the hand and foot are superficial due to the lack of adipose tissue 74  4/19/2024 ©Stanbridge University 2024 Terminology Erythema: Redness of the skin which is caused by an increase in blood flow to the capillaries The increase in blood flow is called Hyperemia which accompanies vasodilation in the surface blood vessels and occurs at 104°-113°F The increased blood flow removes heat from the area and blood that is relatively cooler flows into the area preventing excessive heat accumulation 75  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Heat accumulation is affected by: ▫ Intensity of the stimulus ▫ Duration of the stimulus ▫ Rate of absorption of the tissue Reflex heating of other areas of the body may occur (i.e. heat to the low back can cause vasodilation of the extremities) Local heat has both direct and indirect heating affects 76  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Clinical indications for thermotherapy: ▫ Subacute and chronic conditions ▫ OA/RA ▫ Tightened connective tissue (i.e. scars, superficial joint contractures) ▫ Dysmenorrhea (menstrual cramps) ▫ Sickle cell anemia ▫ Wound healing- increase blood flow and oxygen around the area Metabolic changes ▫ An increase in tissue temperature increases metabolic rate ▫ During acute inflammation heat can exacerbate the inflammatory process 77  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat therapy) Heating agents are ADJUNCTS to achieving functional goals Thermotherapy intervention goals: Pain reduction- Gate Control Theory Reduction of muscle guarding or spasm Elevates the pain threshold Increase tissue extensibility 78  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Tissue Extensibility ▫ Heat decreases the viscosity and increase elastic properties of connective tissue ▫ Sufficient load must be applied for residual elongation ▫ Stretch during heat is best ▫ Temperature range needed is 40°-45°C/104°–113°F (vigorous heat) ▫ Decreased potential for tissue irritation and damage with stretch 79  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) General Procedure for all Thermotherapy Interventions: ▫ Check skin integrity ▫ Remain nearby during treatment ▫ Following the treatment, return equipment to its proper location ▫ Following the intervention, reexamine the patient for their response ▫ Document your findings 80  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Thermotherapy Contraindications: ▫ Areas with acute inflammation ▫ Active bleeding (i.e. acute trauma) ▫ Malignancies ▫ PVD (inability to dissipate heat) ▫ Following a surgical repair or denervation ▫ Thrombophlebitis ▫ Confusion, sedation or coma ▫ Areas with sensory loss ▫ Existing fever ▫ Tissues that are devitalized by x-ray exposure (radiation therapy for cancer patients) 81  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Thermotherapy Precautions ▫ Generalized heat or application to the abdomen or low back during pregnancy ▫ Older adults and children less than 4 years old ▫ Cardiac insufficiency ▫ Existing edema ▫ Over areas on which topical counterirritants have been applied ▫ Over implanted metal close to the skin 82  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Assessment and Effectiveness of thermotherapy can be achieved by using the following outcome measures: ▫ Pain- quantification via scales (VAS) ▫ Range of motion- goniometric measures ▫ Muscle guarding- reflected in joint ROM and muscle flexibility measures 83  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Documentation should include: ▫ Thermal modality used ▫ Method of application ▫ Duration of application ▫ Body area treated ▫ Patient position for intervention ▫ Special precautions or application concerns ▫ Patient response to treatment including adverse responses 84  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Commercial Moist Hot packs (lab) Superficial heat Conduction Immersed in water 158°-167°F 6-8 total layers of towels or commercial covers ▫ Each layer of commercial covers = 2-3 layers of regular towl Needs 20-30 minutes to reheat to temp of water it is stored in Source: Bellew 2016 85  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Hot Pack - Superficial Heat Optimal skin contact is important- choose the right shape Monitor the response in the first 5-10 min 15-30 min for joint structures close to the surface and muscle Maximum skin temp is reached in 6-8 min and maintained up to another 10 min. Muscle depths of 1-2 cm will require longer duration of exposure to reach peak values (15-30 min) At a muscle depth of 3 cm: temperature elevation is about 1.8°F or less 86  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Paraffin Bath (lab) Superficial heat Conduction Kept at 113°-122°F Lower specific heat than water so tolerated better than water Check skin and sensation screen prior to dip All metal jewelry must be removed for safety Do not touch the sides of the bath to avoid burning Dip 6-10 times, 10–15-minute treatment Wrap with plastic and towels to eliminate the escape of heat Source: Bellew 2016 87  4/19/2024 ©Stanbridge University 2024 Fluidotherapy Superficial Heat Method of heating: Convection Dry heat using very fine cellulose particles through which heated air is blown Multiple portals allow the PT to perform ROM activities with the patient during treatment Treatments are delivered at 100°-118°F Time: 15-20 min Frequency: ▫ Subacute: daily ▫ Chronic: Less frequent than daily Normal responses: Pink skin and some perspiration Benefit: Patient’s can perform active exercise while used 88  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Air-Activated Heat wrap Superficial Heat Conduction Maintain temperature of 104°F Can be worn up to 8 hours Follow directions on package Source: Be;;re 2016 Great for travel/work Check skin periodically Do not use >8hrs/day and >7 days/wk 89  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Infrared Superficial heating via radiation Wavelength 780-1500 nm, maximum penetration at 1200 nm Absorbed into first mms of skin Main benefit: Enhancement of soft tissue healing Patient should be 20 inch from source for comfortable level of warmth Light 90° angle to target Duration 15-30min Protective toweling should be placed over tissues outside of target area http://www.tensplus.com/infraredlamp110.asp 90  4/19/2024 ©Stanbridge University 2024 Thermotherapy (Heat Therapy) Evidence An increase in blood flow is seen with Heat + Exercise vs. Heat or Exercise alone  Isometric strength decreases for 30 minutes after application of heat  Isometric strength increases for the next 2.5 hours after the 30 minutes decreases  Muscle endurance decreases after heat application 91  4/19/2024 ©Stanbridge University 2024 Thermotherapy- Evidence I Deep heat is recommended for shoulder adhesive capsulitis. Jain et al., The Journal of Back and Musculoskeletal Rehabilitation, 2014 I Active heat therapy (heat wrap) is suggested for acute low back pain and superficial heat treatment helps resolve DOMS better than cold therapy. Malanga et al., Postgrad Med, 2015 92  4/19/2024 ©Stanbridge University 2024 Thermotherapy- Evidence I Use of heat and exercise benefits pain and stiffness in patients with RA Ottawa panel evidence-based clinical practice guidelines for electrotherapy and thermotherapy interventions in the management of rheumatoid arthritis in adults; Physical Therapy; 84(1):1016-1043 Low to no evidence for the use of thermotherapy for osteoarthritis Zhang et al. Osteoarthritis and Cartilage, 2008 Jamtvedt et al. Physical Therapy, 2008 93