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Chapter 4: Thermotherapy and Cryotherapy. © 2009 McGraw-Hill Higher Education. All rights reserved. Infrared Modalities Most of the heat and cold modalities.

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Presentation on theme: "Chapter 4: Thermotherapy and Cryotherapy. © 2009 McGraw-Hill Higher Education. All rights reserved. Infrared Modalities Most of the heat and cold modalities."— Presentation transcript:

1 Chapter 4: Thermotherapy and Cryotherapy

2 © 2009 McGraw-Hill Higher Education. All rights reserved. Infrared Modalities Most of the heat and cold modalities have wavelengths and frequencies that fall in the infrared portion of the electromagnetic spectrum Ice Massage Commercial cold packs Ice packs Cold whirlpool Cold spray Contrast Baths Ice immersion Cryo-cuff Cryokinetics Warm whirlpool Hydrocollator packs Paraffin baths Infrared lamps Fluidotherapy

3 © 2009 McGraw-Hill Higher Education. All rights reserved. While these modalities are considered infrared modalities they may be better described as conductive thermal energy modalities Typically used to produce a local and/or generalized heating/cooling effect –Cryotherapy –Thermotherapy

4 © 2009 McGraw-Hill Higher Education. All rights reserved. Mechanisms of Heat Transfer Transmission of heat occurs by three mechanisms: Conduction Convection Radiation *Conversion (involves change in one energy form to another)

5 © 2009 McGraw-Hill Higher Education. All rights reserved. Appropriate Use of Infrared Modalities Thermotherapy –Heating techniques used for therapeutic purposes –Used when a rise in tissue temperature is the goal of treatment Cryotherapy –Used in the acute stages of the healing process immediately following injury when a loss of tissue temperature is the goal of therapy

6 © 2009 McGraw-Hill Higher Education. All rights reserved. Appropriate Use of Infrared Modalities Cold application is often continued throughout the rehabilitation and re- conditioning process of an injury Hydrotherapy is also included (hot or cold) as water can be used as the medium through which heat is transferred

7 © 2009 McGraw-Hill Higher Education. All rights reserved. Appropriate Use of Infrared Modalities Knowledge of the injury mechanism, pathology and healing process are critical when determining appropriate hot and cold application Simple, efficient, and inexpensive means of patient care

8 © 2009 McGraw-Hill Higher Education. All rights reserved. Clinical Use of Conductive Energy Modalities Physiologic effects are rarely the result of direct absorption of infrared energy No form of infrared energy can have a depth of penetration greater than 1 cm Effects of infrared modalities are primarily superficial and directly affect cutaneous blood vessels and nerve receptors

9 © 2009 McGraw-Hill Higher Education. All rights reserved. If significant amounts of energy are absorbed over time, temperature of circulating blood will increase –Hypothalamus reflexively increase blood flow to the area –The reverse is true with cold application –Deep heating modalities (US, diathermy) may be more beneficial when increased blood flow to deeper tissues is desired

10 © 2009 McGraw-Hill Higher Education. All rights reserved. Most effective use of infrared modalities should be to provide analgesia or reduce sensation of pain associated with injury –Gate control theory of pain modulation Pain reduction to facilitate therapeutic exercise is common practice Continued research and investigation is necessary to provide athletic trainers with effective and efficient means of injury treatment

11 © 2009 McGraw-Hill Higher Education. All rights reserved. Effects of Tissue Temperature Change on Circulation Main physiologic effect is on superficial circulation –Changes due to response of temperature receptors in skin and sympathetic nervous system When cold is applied the skin vessels progressively constrict to a temperature of about 15° C (59° F) at which point they reach maximum constriction

12 © 2009 McGraw-Hill Higher Education. All rights reserved. Effects of Tissue Temperature Change on Circulation At temperatures below 15° C vessels begin to dilate –Caused by paralysis of contractile mechanism in vessel wall or blockage of nerve impulses General exposure to cold causes sympathetic nerves to elicit cutaneous vasoconstriction, shivering, piloerection, and an increase in epinephrine secretion so vascular contraction occurs

13 © 2009 McGraw-Hill Higher Education. All rights reserved. Simultaneously, metabolism and heat production increase –Aids in increasing core temperature Increased blood flow will also result in increasing oxygen to the area –Results in analgesic and relaxation effects on muscle spasm –Increased proprioceptive reflex may explain these effects

14 © 2009 McGraw-Hill Higher Education. All rights reserved. Three types of sensory receptors in sub- epithelial tissue –Cold, warm, pain –Each responds differently at different temperatures –Adapt to changes in temperature, with rapid temperature change = more rapid adaptation Stimulation of larger surface areas results in summation of thermal signals trigger vasomotor centers in hypothalamus

15 © 2009 McGraw-Hill Higher Education. All rights reserved. Effects of Tissue Temperature Change on Muscle Spasm Physiologic mechanisms underlying the effectiveness of heat and cold treatments in reducing muscle spasm lie at level of muscle spindle and Golgi tendon organs Heat relaxes muscles simultaneously lessening stimulus threshold of muscle spindles and by decreasing gamma efferent firing rate –Thus muscle spindles are more easily excited

16 © 2009 McGraw-Hill Higher Education. All rights reserved. Effects of Tissue Temperature Change on Muscle Spasm Muscles may be electromyographically silent while at rest during application of heat, but the slightest amount of voluntary or passive movement may cause the efferents to fire Local applications of cold decrease local neural activity

17 © 2009 McGraw-Hill Higher Education. All rights reserved. Effects of Tissue Temperature Change on Muscle Spasm Cold raises the threshold stimulus of muscle spindles, and heat tends to lower it Local cooling results in a significant reduction of muscle spasm greater than with use of heat Unclear if reduction of spasticity is caused by excitability of motor neurons or hyperactivity of gamma systems Cold effective in modifying stretch-reflex mechanism

18 © 2009 McGraw-Hill Higher Education. All rights reserved. Effects of Tissue Temperature Change on Muscle Spasm Nerve conduction velocity reduction also occurs with cold application –Decreases afferent discharge from cutaneous receptors

19 © 2009 McGraw-Hill Higher Education. All rights reserved. Effects of Tissue Temperature Change on Performance Cryotherapy –Some disagreement on relative concentric and eccentric torque capabilities –May not increase torque but may improve endurance –Decreases vertical jump –No impact joint range of motion –Negatively impacts functional performance, which can be negated via an active warm-up –Minimal or no effect on joint position sense, proprioception, balance and agility

20 © 2009 McGraw-Hill Higher Education. All rights reserved. Effects of Tissue Temperature Change on Performance Thermotherapy –Minimal or no effect on joint position sense, proprioception, and balance

21 © 2009 McGraw-Hill Higher Education. All rights reserved. Cryotherapy: Physiologic Effects of Tissue Cooling General agreement that cold should be initial treatment for musculoskeletal injuries –Primary reason is to lower temperature in injured area reduces metabolic rate with a corresponding decrease in production of metabolites and metabolic heat (secondary hypoxic response) More effective when combined with compression –Promotes vasoconstriction and helps to control hemorrhaging and edema

22 © 2009 McGraw-Hill Higher Education. All rights reserved. Cryotherapy: Physiologic Effects of Tissue Cooling Used immediately after injury to decrease pain and muscle spasm –Result of decreased nerve conduction velocity –Cold stimulus bombards sensory receptors resulting in pain modulation through gate control Effective in treating myofascial pain Effective in treating acute muscle pain as opposed to delayed onset muscle soreness

23 © 2009 McGraw-Hill Higher Education. All rights reserved. Cryotherapy: Physiologic Effects of Tissue Cooling Reduction in muscle guarding has been observed clinically Initial reaction of body to cold is local vasoconstriction –Results in decreased nutrient and phagocyte delivery to area Hunting Response –Periods of vasodilation and constriction following prolonged cold application to limit possible tissue injury due to cold use

24 © 2009 McGraw-Hill Higher Education. All rights reserved. Cryotherapy: Physiologic Effects of Tissue Cooling Cooling for too long may be detrimental to healing Ice application for 20 min. = decreased muscle blood flow –However, effects of ice application diminishes with increased tissue depth Length of cooling required is dependent on subcutaneous tissue thickness –Recommended treatment times = 5-45 minutes

25 © 2009 McGraw-Hill Higher Education. All rights reserved. Cryotherapy: Physiologic Effects of Tissue Cooling Ability to lower tissue temperature is dependent upon: –Type of cold applied to the skin –Thickness of subcutaneous fat –Region of the body

26 © 2009 McGraw-Hill Higher Education. All rights reserved. Cryotherapy: Physiologic Effects of Tissue Cooling Cold application results in: –Decreased cell permeability and metabolism –Decreased edema accumulation Should be continued in 5-45 minute applications for up to 72 hours initially

27 © 2009 McGraw-Hill Higher Education. All rights reserved. Cryotherapy Techniques Cryotherapy techniques include –Ice massage –Cold packs –Ice packs –Cold whirlpool –Cold spray –Contrast baths –Ice immersion –Cryo-cuff –Cryokinetics

28 © 2009 McGraw-Hill Higher Education. All rights reserved. Cryotherapy Techniques Application of cryotherapy produces a three- to four-stage sensation –Uncomfortable sensation of cold –Stinging –Burning or aching feeling –Numbness Caution should be exercised when applying intense cold directly to the skin

29 © 2009 McGraw-Hill Higher Education. All rights reserved. Ice Massage Often indicated with conditions requiring stretching Appears to cool area faster than ice bag application Procedures: –Remove top 2/3 of paper or styrofoam cupleaving 1on bottom of cup as handle –Apply using overlapping circular or longitudinal stroke –When skin is numb to fine touch treatment ends(10-20 min)

30 © 2009 McGraw-Hill Higher Education. All rights reserved. Commercial Cold Packs Indicated for acute musculoskeletal injuries Procedures –Cold pack should be placed against wet toweling and covered with a towel to limit environmental warming –Mold cold pack around joint –Treatment time required is about 20 minutes

31 © 2009 McGraw-Hill Higher Education. All rights reserved. Ice Packs Indicated for acute injuries and prevention of swelling following exercise of injured area Procedures: –Flaked or cubed ice in a plastic bag large enough for the area to be treated –Applied directly to skin and held in place by a moist or dry elastic wrap –Can be molded to body part

32 © 2009 McGraw-Hill Higher Education. All rights reserved. Cold Whirlpool Indicated in acute and sub- acute situations where exercise in cold environment is desired Must be mindful of gravity dependent position Procedures –Fill appropriate size whirlpool with cold water and flaked ice with temp. at 50° to 60° F –Use for massaging action

33 © 2009 McGraw-Hill Higher Education. All rights reserved. –Most intense application of cryotherapy Inability to develop thermopane (insulating layer of water) due to water turbulence Convection provides for continuous circulation of cold water Results in significantly longer periods of temp. reduction following treatment Additional care must be used with total body immersion With increased treatment area systemic effects are possible –Equipment maintenance and cleaning are critical

34 © 2009 McGraw-Hill Higher Education. All rights reserved. Cold Spray and Stretch Flourimethane is used Acts as a counterirritant to block pain Cooling is superficial without significant penetration Useful in treating trigger points Not effective in treating edema or hemorrhaging Indicated in situations where cooling and stretching are desired

35 © 2009 McGraw-Hill Higher Education. All rights reserved. Procedure –Spraying technique Same direction, even sweeps Work proximal to distal For trigger points, work from point to referred pain area Affected muscles should be sprayed from the affected area to the insertion Static stretching can be incorporated as you spray

36 © 2009 McGraw-Hill Higher Education. All rights reserved. Contrast Baths Used to treat subacute swelling Does not reduce edema through pumping action as suggested Uses alternating hot ( o ) and cold (50-60 o ) immersions 3:1 or 4:1 heat:cold ratios have been recommended Best used as a transition from cold to heat

37 © 2009 McGraw-Hill Higher Education. All rights reserved. Cold Compression Units: Cryo-cuff Used both acutely following injury and post-surgically Applies both cold and compression simultaneously Ice chills water which flows into sleeve from cooler As cooler is raised pressure in cuff is increased

38 © 2009 McGraw-Hill Higher Education. All rights reserved. Cryokinetics Combines cryotherapy with exercise Goal is to numb injured part (12-20 min) then work toward achieving normal ROM through progressive active exercise Numbness usually last for 3-5 min. at which point ice is reapplied for 3-5 minutes until numbness returns –Can be repeated five times Exercises should be pain free and progressive in intensity concentrating on both flexibility and strength

39 © 2009 McGraw-Hill Higher Education. All rights reserved. Ice Immersion Ice buckets allow ease of application (50-60 o ) Container should be large enough to allow for movement of body segment if being used for cryokinetics Body segment is subject to gravity-dependent positions Cold pain may be more significant than that experienced with cold pack application

40 © 2009 McGraw-Hill Higher Education. All rights reserved. Thermotherapy: Physiologic Effects of Tissue Heating Local superficial heating (infrared heat) is recommended in subacute conditions for reducing pain and inflammation through analgesic effects During later stages of healing a deeper heating effect is desirable and should be achieved using the diathermies or ultrasound

41 © 2009 McGraw-Hill Higher Education. All rights reserved. Thermotherapy Physiologic Effects of Tissue Heating Increase in temperature increases metabolism –13% increase in metabolism for each 1° C Superficial heat vasodilates vessels, which increases capillary blood flow thus increasing tendency toward formation of edema –In mild or moderate inflammation increased capillary blood flow causes an increase in supply of oxygen, antibodies, leukocytes, and other nutrients and enzymes, along with clearing of metabolites

42 © 2009 McGraw-Hill Higher Education. All rights reserved. Thermotherapy Physiologic Effects of Tissue Heating Used to produce an analgesic effect through gate control –Most frequent indication for the use Heat is applied in musculoskeletal and neuromuscular disorders Increases the elasticity and decreases the viscosity of connective tissue

43 © 2009 McGraw-Hill Higher Education. All rights reserved. Thermotherapy Physiologic Effects of Tissue Heating Produces a relaxation effect and a reduction in muscle guarding by: –Relieving pain –Lessening hypertonicity of muscles –Producing sedation –Decreasing spasticity, tenderness, and spasm –Decreasing tightness in muscles and related structures

44 © 2009 McGraw-Hill Higher Education. All rights reserved. Thermotherapy Physiologic Effects of Tissue Heating Primary goals of thermotherapy include –Increased blood flow –Increased muscle temperature to stimulate analgesia –Increased nutrition to the damaged cells –Reduction of edema –Removal of metabolites and other products of inflammatory process

45 © 2009 McGraw-Hill Higher Education. All rights reserved. Thermotherapy Techniques Warm Whirlpool Hydrocollator Packs Paraffin Bath Infrared Lamps Fluidotherapy

46 © 2009 McGraw-Hill Higher Education. All rights reserved. Warm Whirlpool Temperature Range –Upper Extremity 98° -110° F –Lower Extremity ° F –Full body 98° - 102° F Time of application should be 15 to 20 minutes Caution is indicated in gravity-dependent position in subacute injuries Whirlpool maintenance

47 © 2009 McGraw-Hill Higher Education. All rights reserved. Warm Whirlpool Provides massaging effect and will stimulate circulation –Monitor for changes in edema Excellent post-surgical modality –Increases systemic blood flow and mobilization of body part Also noted to be one of the most abused clinical modalities

48 © 2009 McGraw-Hill Higher Education. All rights reserved. Hydrocollator Packs Canvas pouches of petroleum distillate Water temperature 170 o 6 layers (1) of toweling recommended Dont lie on top of hot pack!! Time of application should be 15 to 20 minutes

49 © 2009 McGraw-Hill Higher Education. All rights reserved. Paraffin Baths Mixture ratio of paraffin to mineral oil (2 lbs : 1 gallon) Mineral oil reduces temp of the paraffin to 126° F Extremity dipped into paraffin for a couple of seconds then removed to allow paraffin to harden

50 © 2009 McGraw-Hill Higher Education. All rights reserved. Paraffin Bath Repeat until 6 layers have accumulated Wrap in a plastic bag with several layers of toweling Must exercise caution with use to reduce chance of burning patient

51 © 2009 McGraw-Hill Higher Education. All rights reserved. Fluidotherapy Dry heat modality that uses a suspended air stream of corn husks Recommended temperatures vary by body part & tolerance in a range of 110° to 125°F Active and passive exercise is encouraged during treatment Treatments are approximately 20 minutes

52 © 2009 McGraw-Hill Higher Education. All rights reserved. Fluidotherapy Medium allows for much higher treatment temperatures –Skin irritation and thermal shock limited as well –Mechano- and thermoreceptor stimulation reduces pain sensitivity (counterirritation) Pressure may assist with edema reduction Increases blood flow, sedates blood pressure, accelerates biochemical reactions

53 © 2009 McGraw-Hill Higher Education. All rights reserved. ThermaCare Wraps Cloth like material that conforms to body Contains iron, charcoal, table salt and water that heat up when exposed to oxygen Shown to be effective in increasing tissue temp. up to 2cm

54 © 2009 McGraw-Hill Higher Education. All rights reserved. Infrared Lamps Superficial tissue temperature can be increased even though unit does not touch patient Seldom used because of limited depth of skin penetration (<1mm) Moist towels should cover the area to be treated Distance from treatment area to lamp should be adjusted according to treatment time 20 inches = 20 minutes

55 © 2009 McGraw-Hill Higher Education. All rights reserved. Infrared Lamps Luminous and non-luminous infrared lamps are classified as electromagnetic energy modalities –Effects on tissue temperature are not related to conduction Non-luminous –Metal coil wrapped around core of non-conducting material No longer used Luminous –Tungsten filament and quartz red lamps

56 © 2009 McGraw-Hill Higher Education. All rights reserved. Counterirritants Not classified as infrared modalities Topically applied ointments that chemically stimulate sensory receptors of the skin Contains –Menthol –Methyl salicylate –Camphor –Capsaicin

57 © 2009 McGraw-Hill Higher Education. All rights reserved. Counterirritants Ingredients have been shown to be effective in reducing chronic pain and provide analgesic effects Mechanism of pain relief not understood –Application alone may trigger gate control theory –May stimulate both noxious and thermal receptors Capsaicin is thought to have preferential action on C- fibers, stimulating release and depletion of substance P Capsaicin may also affect synapses of spinothalamic tract

58 © 2009 McGraw-Hill Higher Education. All rights reserved. Summary Indications for Cryotherapy Acute or subacute inflammation Acute pain Chronic pain Acute swelling Myofascial trigger points Muscle guarding Muscle spasm Acute muscle strain Acute ligament sprain Acute contusion Bursitis Tenosynovitis Tendinitis Delayed onset muscle soreness

59 © 2009 McGraw-Hill Higher Education. All rights reserved. Summary Contraindications for Cryotherapy Impaired circulation Peripheral vascular disease Hypersensitivity to cold Skin anesthesia Open wounds or skin conditions (cold whirlpools and contrast baths) Infection

60 © 2009 McGraw-Hill Higher Education. All rights reserved. Summary Indications for Thermotherapy Subacute and chronic inflammatory conditions Subacute or chronic pain Subacute edema removal Decreased ROM Resolution of swelling Muscle guarding Muscle spasm Subacute Muscle strain Subacute Ligament sprain Subacute contusion Infection Myofascial trigger points

61 © 2009 McGraw-Hill Higher Education. All rights reserved. Summary Contraindications for Thermotherapy Acute musculoskeletal conditions Impaired circulation Peripheral vascular disease Skin anesthesia Open wounds or skin conditions (cold whirlpools and contrast baths)


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