Week 2 - Therapeutic Heat Lecture - SV-1 PDF

Therapeutic Heat DPT 5540 – Therapeutic Modalities DPT 5540– Spring/Dr. Holmes  Lecture Objectives 01 02 03 04 Understand the Understand the Recognize Effectively...

Therapeutic Heat DPT 5540 – Therapeutic Modalities DPT 5540– Spring/Dr. Holmes  Lecture Objectives 01 02 03 04 Understand the Understand the Recognize Effectively biophysical basic physical indications, assess outcomes effects of principles of contraindications, following temperature thermotherapy and precautions treatment elevation for heat therapy DPT 5540– Spring/Dr. Holmes  Clinical Scenario The patient is a 55 year-old male who complains of severe “stiffness” in the left shoulder. Range of motion is significantly limited with elevation. Onset of symptoms was gradual over a 6-month time frame. The goal is to stretch out the shoulder. Would you choose hot or cold? Why? What specifically would you use and why? DPT 5540– Spring/Dr. Holmes  Thermotherapy Modalities Heat superficial joints Cause a heating effect in deeper structures through reflex mechanisms Heat soft tissue to increase its extensibility DPT 5540– Spring/Dr. Holmes  Thermal Modality Options Increase temperature 1-3 cm Moist heat packs Paraffin wax Fluidotherapy Warm whirlpool Microwavable gel packs Air-activated heat wraps Electric heating pads Increase temperature 1-5 cm Continuous ultrasound Shortwave diathermy DPT 5540– Spring/Dr. Holmes  Heating Heating – nonmechanical energy transfer with reference to a temperature difference between a system and its surroundings Heat always moves toward cool or cold DPT 5540– Spring/Dr. Holmes  Heat vs. Temperature Heat is energy – temperature is the measure of heat Heat energy depends on:  Speed of particles (kinetic energy)  Number of particles (mass)  Capacity to store heat (specific heat) DPT 5540– Spring/Dr. Holmes Properties Specific Heat Thermal Conductivity (c) (k) Aluminum 0.22 487.00 Air 0.24 0.02 Paraffin Oil 0.45 0.59 Ice 0.46 5.28 Water 1.00 1.42 Muscle 0.90 1.53 Skin 0.90 0.90 Subcutaneous fat 0.55 0.45 Blood 0.87 1.31 Bone 0.38 2.78 DPT 5540– Spring/Dr. Holmes  Heating Modes for energy transfer  Conduction  Moist heat packs  Paraffin wax  Electric heating pads  Air-activated heat wraps  Convection  Fluidotherapy  Radiation  Infrared DPT 5540– Spring/Dr. Holmes  Conduction Conduction – the transfer of heat by direct interaction of molecules (e.g., hot pack)  D = (Area) x k x (T1 – T2)/(thickness of tissue) DPT 5540– Spring/Dr. Holmes  Conduction Quality of heat gained depend on several factors  Thermal conductivity of the tissues  Body volume exposed  Time of exposure Local effects  blood flow, vasodilation,  tissue temperature DPT 5540– Spring/Dr. Holmes  Convection Convection – bulk movement of moving molecules, either in liquid or gaseous form, that transfers heat from one place to another  Warm whirlpool  fluidotherapy DPT 5540– Spring/Dr. Holmes  Radiation Radiation - the direct transfer of energy from a substance with a higher temperature to one of a lower temperature without need of direct contact (usually in the form of waves) Infrared lamps DPT 5540– Spring/Dr. Holmes Biophysical Effects of Temperature Elevation Factors that determine the effects of heat Extent of tissue temperature rise (TTR) Rate at which energy is being transferred Volume of tissue Composition of tissue Capacity of tissue to dissipate heat (e.g. blood supply) Therapeutic level = 40°C–45°C (104°F– 113°F) >113 °F damage tissue 25% body fat  Difficulty increasing temp in muscle under adipose tissue  Increase risk of burn to skin (skin temp even more in these patients) DPT 5540– Spring/Dr. Holmes  Conductive Heat Modalities Moist heat packs  Hydrocollator – between 158-165 ºF  6–8 layers (Quality matters!)  Do not lie on hot pack (or put more barriers) Advantages  Ease of prep and application; variety of shapes; moist, comfortable heat; relatively inexpensive Disadvantages  No temperature control; does not readily conform; sometimes awkward to secure; does not retain heat > 20 min; passive intervention-cannot exercise DPT 5540– Spring/Dr. Holmes  Conductive Heat Modalities Paraffin wax  Molten state allows even distribution of heat  Low specific heat,↓ risk of burns  Conducts heat more slowly than water  Temperature of 116 – 126ºF; typically use 122ºF  2 primary forms of applications  Dip and wrap (Dip 8-10 times, 15-30 minutes*)  Dip and reimmerse (10-20 minutes)  Paintbrush (10 coats)  May not be significantly better at decreasing pain or increasing ROM compared to other heat modalities DPT 5540– Spring/Dr. Holmes  Conductive Heat Modalities Advantages Paraffin  Low specific heat allows for application @ higher temp than water w/o risk of a burn  Low thermal conductivity allows for heating of tissues to occur more slowly, thus the risk of overheating the tissues  Molten state allows for even distribution of heat to areas (fingers and toes)  First dip traps air and moisture to create more even heat distribution  Oils used in the wax add moisture to the skin  Wax remains malleable after removal, allowing use for exercises  Provides a comfortable, moist heat  Replacing the wax is relatively inexpensive Disadvantages  Effective only for distal extremities  No method of temperature control once applied  Heating lasts only ~ 20 minutes  A passive intervention; exercise cannot be performed simultaneous DPT 5540– Spring/Dr. Holmes  Clinical Procedures for Use of Paraffin Wax Normally stored in a wax bath container between 113°F and 129°F (45°C and 54°C) General procedures: 1. Have/assist patient wash body part to be treated 2. Do not treat areas with open wounds, cuts, etc., unless properly bandaged and insulated 3. Remove patient’s clothing and jewelry as necessary 4. Gather towel or commercial wax bath sleeve and plastic bag 5. Remove lid from wax bath DPT 5540– Spring/Dr. Holmes Clinical Procedures for Use of Paraffin Wax cont’d 6. Instruct patient in dipping procedure: first dip to cover entire treatment area plus about 2 inches more subsequent dips to cover less than first dip after each dip, lift body part out of wax bath and hold until dripping stops, then dip again dip a total of 6 to 10 times 7. After final dip, replace lid on wax bath 8. Cover treatment area with a plastic bag then wrap with a towel or commercial terry towel sleeve 9. Return patient to a comfortable resting position 10. At end of treatment (15 to 20 minutes), remove towel and plastic bag 11. Have patient try to remove wax without assistance—this provides a form of therapeutic exercise 12. Inspect treatment area (Skin will be pink and moist) 13. Have patient exercise with warm moist wax DPT 5540– Spring/Dr. Holmes  Conductive Heat Modalities Electric heating pads  Used primarily at home Advantages  Readily available at reasonable cost  Convenient method of at home application  Provides comfortable heat sensation Disadvantages  Can cause skin and subcutaneous tissue burns  Patient must be near electrical outlet  A passive intervention-cannot exercise with pad in place DPT 5540– Spring/Dr. Holmes  Conductive Heat Modalities Air-activated, wearable heat wraps  Temperature around 104 deg F  Wear up to 8 hours Advantages  Dry heat prevents clothing from getting wet  Wraps comfortable and low-profile  Can be worn during activity and sleep  Pts. instructed in safe application  Relatively inexpensive for short-term use  Active exercises can be performed  Do not heat up to more than 104F (40C) Disadvantages  Only used once  Needed for extended periods can get expensive DPT 5540– Spring/Dr. Holmes  Convective Heating Fluidotherapy  Air-fluidized solids  Forced convection  Distal extremities  Variable temperature, agitation  Typically, 102-118F (38.8to 47.8)  Lower ranges for beginning desensitization programs or predisposition for edema  Perform exercises while receiving heat DPT 5540– Spring/Dr. Holmes  Convective Heat Modalities Advantages Fluidotherapy  Convenient and easy to administer  Temperature of application can be controlled  Agitation of dry particles can be controlled for comfort  Variety of unit sizes allows for most body areas (distal) to be treated  Allows for some active exercise to be carried out during intervention  Provides a dry, comfortable heat  Can be used for desensitization of hypersensitive hands/fingers or feet/toes Disadvantages  A relatively expensive modality to purchase  Some patients are intolerant to the enclosed container (claustrophobic feeling)  Some patients are intolerant to the dry materials used DPT 5540– Spring/Dr. Holmes  Contrast Baths Combination hot/cold  Hot water: 100-110ºF  Cold water: 55-65ºF Place extremity in hot water 3-4 minutes, then cold 1-2 minutes  Times can vary but ration of 3:1 or 4:2 typically used Can end in hot or cold depending on condition Cycle thought to trigger vascular pumping action DPT 5540– Spring/Dr. Holmes Clinical Application: Principles and Indications (Heating) ↓ pain and stiffness Alleviate muscle spasm ↑ ROM Improve tissue healing by ↑ blood flow 15–30 minutes DPT 5540– Spring/Dr. Holmes  Contraindications to Thermotherapy Large areas, or at a sufficient intensity to raise core temperature, in pregnant women Regions of known or suspected malignancy Infected tissues/tuberculosis Tissues inflamed due to recent injury or exacerbation of chronic inflammatory condition Persons with active DVT or thrombophlebitis Areas of impaired sensation Areas of recent/potential hemorrhage DPT 5540– Spring/Dr. Holmes  Contraindications to Thermotherapy Large areas in persons with severe cardiac disease or failure Areas of impaired circulation Areas affected by heat-sensitive skin diseases Areas of skin breakdown or damage Areas of severe edema Reproductive organs (testes) Recently radiated tissues Recently applied liniments or heat rubs Unreliable situations (e.g. language barriers, cognitive impairments that prohibit giving accurate and timely feedback) DPT 5540– Spring/Dr. Holmes  Precautions to Thermotherapy Areas near or over eyes Anterior neck and carotid sinus Pregnant women People with cardiac failures For Fluidothepapy: Corn/cellex allergy DPT 5540– Spring/Dr. Holmes  No Contraindications/Precautions Intact skin overlying implants containing metal, plastic, or cement Areas over electronic devices Areas near chronic wounds Superficial or regenerating nerves The head, chest, or heart Areas over active epiphysis Persons with hypertension DPT 5540– Spring/Dr. Holmes  General Method for Application Perform appropriate evaluation: history, co- Remove jewelry and Determine appropriate Explain procedure morbidities, age, clothing from the area goals for intervention and expectations inspection of to be effected treatment area Insure the patient’s Apply the modality Provide bell / call Check on patient comfort accordingly button for safety periodically Appropriately document: Inspect area after parameters used, area completion of treated, patient response, treatment skin appearance DPT 5540– Spring/Dr. Holmes  Safety HPSO 2020 report  Data from 2015 to 2019; payment >$10,000 16.1% of claims related to “Improper performance using a biophysical agent” Allegation % of claims Injury during electrotherapy 50.8% Injury during heat therapy or hot packs 32.8% Use of unapproved/improper equipment 6.6% Injury related to iontophoresis 4.9% Injury from cold packs/ice 1.6% DPT 5540– Spring/Dr. Holmes  Clinical Decision-Making Heat vs. Cold Consider: diagnosis, medical status, objective findings Only one heating modality per session Heat vs. cold  Stage of injury/disease (i.e. acute = cold)  Area of body  Medical status  Patient preference  Indications/contraindications of each DPT 5540– Spring/Dr. Holmes  Heat vs. Cold HEAT Advantages Disadvantages ¯ Pain May cause  swelling ¯ Stiffness  Tissue extensibility COLD Advantages Disadvantages May prevent further swelling ­ Stiffness  pain  Tissue extensibility DPT 5540– Spring/Dr. Holmes  Clinical Decision-Making Superficial vs. deep heat  Superficial tissues: moist heat  Deep tissues: ultrasound or diathermy Wet vs. dry heat Home application  Safety considerations DPT 5540– Spring/Dr. Holmes  Assessment of Effectiveness and Expected Outcomes Pain, ROM, muscle guarding, functional movements Documentation  Modality used  Method of application  Duration  Body area  Patient position  special precautions DPT 5540– Spring/Dr. Holmes  Thermotherapy to Increase ROM Heat commonly applied before or during stretching or mobilizations  Application of superficial heat in conjunction with static stretch improves ROM at shoulder, hip, ankle  Deep heating may be more useful at heating tissues contributing to loss of ROM  Moderate evidence to support joint mobilization and exercise to help ROM DPT 5540– Spring/Dr. Holmes  Thermotherapy in Tissue Healing Studies using superficial heat to promote tissue healing are lacking Increased skin temperature, increases vasodilation, increases metabolism  May assist tissue healing May also assist tissue healing with effect on muscle spams DPT 5540– Spring/Dr. Holmes  Thermotherapy in Pain Management Increase blood flow, supplying nutrients and removing pain-inducing chemical mediators Improves soft tissue extensibility, can reduce soft tissue tension Ease of movement may add to perception of decreased pain DPT 5540– Spring/Dr. Holmes  Soften scars Collagen Stretch collagen extensibility  joint stiffness Fluid viscosity  Assist healing Cellular activity and accelerate  repair Metabolism  Products of Blood flow  metabolism  hyperemia e.g. CO2, lactate HEAT Causing local rise in Dilation of arterioles, temperature capillaries, and venules RELIEF OF PAIN Axon reflex Muscle spasm  Nerve stimulation Analgesic effect Proprioceptors? Hypothalamus General regulation of Sedative effect? body heat: vasomotor Cutaneous heat Sweating receptors Cardiac effects To cortex Aware of heat DPT 5540– Spring/Dr. Holmes  Clinical Scenario The patient is a 55 year-old male who complains of severe “stiffness” in the left shoulder. Range of motion is significantly limited with elevation. Onset of symptoms was gradual over a 6-month time frame. The goal is to stretch out the shoulder. DPT 5540– Spring/Dr. Holmes  Clinical Decision Making Does the patient have a dysfunction, limitation, or problem that can be improved with the use of thermotherapy? Patient appropriate for thermotherapy? What are the specific goals to be achieved with use of thermotherapy? What specific form of thermotherapy would be appropriate for the patient? What specific parameters of the form is appropriate? DPT 5540– Spring/Dr. Holmes  Summary Use sound clinical judgment to select appropriate heating modality Consider: indications, PMH, area to be treated, contraindications, precautions, patient preference, availability, deep vs. superficial Assess outcomes after Adverse effects, pain, muscle guarding, ROM, treatment patient response DPT 5540– Spring/Dr. Holmes