Thermotherapy Use during subacute and chronic stages Classified

Thermotherapy Use during subacute and chronic stages Classified as superficial or deep Mottling: blotchy discoloration of the skin Superficial: capable of skin temperature between 104°-113°F • Transfer of heat occurs through conduction • Depth of heating effects – less than 2 cm • • • Deep: Ultrasound & Shortwave Diathermy • Depth of heating effects – greater than 2 cm

Thermotherapy Effects • Local Effects metabolic rate Vasodilation capillary permeability nerve conduction velocity – pain – muscle spasm – Edema formation – – • Systemic Effects – – body temperature pulse rate respiratory rate blood pressure

Cellular & Blood/Fluid Responses • Cellular – – temperature cell metabolism O 2; cell waste excreted – temperature blood hemoglobin releases O 2 (106°F = twice as much O 2 released) – temperature (104°-113°F) plastic deformation of collagen-rich tissues occurs more easily • Blood & Fluid Dynamics – – b. flow edema, but b. flow removes wastes, etc. – Triggers release of bradykinin

Nerve Conduction • chemical reactions & cell metabolism nerve conduction • Pain Control – – circulation congestion in area – Mechanical pain by reducing pressure on nerves (swelling is removed) • Analgesic effect

Thermotherapy Effects • First 5 -6 minutes: body absorbs heat faster than it can dissipate it • After 7 -9 minutes: temperature gradients begin to even out & slightly decline • Then, the body begins to counteract the energy. – It supplies blood to the area to cool it down (tries to prevent burning) limiting the amount of heating that can occur

Rebound Vasoconstriction • Approximately 20 min. into treatment (after maximum vasodilation has occurred & intensity of treatment stays constant) vessels constrict

Indications • • • Subacute & chronic phases ROM Lymphatic drainage Blood flow Cellular metabolic rate Body temperature Pulse rate Respiratory rate Pain Muscle spasm

Contraindications Acute injury Open wounds Heat stress/illness Neurovascular deficits (loss of sensation & impaired circulation) • Thrombophlebitis (clot can be dislodged) • Neoplasm (abnormal tissue (tumor) that grows at expense of healthy tissue) • •

• Adipose tissue – primary limiting factor for effective depth of heat penetration – As the thickness , more of the heating agent is absorbed in this layer. – Doesn’t allow deeper tissues to increase in temp. • Following thermotherapy, skin and adipose tissue temps. rapidly (heat lost to surrounding tissues) – Increased circulation of cool blood • Intramuscular temps can remain elevated approx. 30 minutes

Precautions • Prevent burning – if too hot, may have to add more toweling or decrease modality temp. (e. g. warm whirlpool – add cold water) • Mottling – blotchy discoloration of skin

Application of Thermotherapy • Hydrocollator Pack (Moist Heat) – Hot pack – 170°F – 6 layers of toweling – (terry cloth cover = 4) – Watch for burning skin • Warm Whirlpool – Water massages tissue – Never exceed 115°F • Heat Lamps • Fluidotherapy – Dry warm whirlpool • Heating Pads

Application of Thermotherapy • Paraffin Bath - 125°-127°F – – – – Remove all jewelry Wash hand Place hand in wax (1 -2 sec. ) then remove Repeat 4 -5 times (1 st layer must be the highest on the hand) Place in plastic bag Wrap towel around 20 -30 min. application • Analgesic Balm - counterirritant – Lack of thermal response research – large-diameter afferent input

Which One Should be Used? • You must know the healing phases • Answer the following questions – Does the body area feel warm to the touch? – Is the injured area still sensitive to light to moderate touch? – Does the amount of swelling continue to over time? – Does swelling during activity (joint motion)? – Does pain limit the joint’s ROM? – Would you consider the acute inflammation process to still be active? – Does the patient continue to display improvement with the use of cold modalities? • If all of the answers are “no”, then heat can be safely used. If “yes” is the answer to several of the questions then cold should be used.

Modes of heat transfer • Conduction-transfer of heat between 2 objects. Direct contact. HP, paraffin • Convection-transfer of heat between a surface & a moving medium such as water, air or other matter. WP or Fluidotherapy • Conversion-Transference of 1 form of energy into heat. US

Superficial Vs. • Heat applied to the skin – HP – Paraffin – Fluidotherapy • Depth of heating -. 5 CM greatest heating, but 1 -2 CM heating achieved in 15 -30 minutes Deep Heat • Heat penetrates into tissue – Ultrasound – Depth of heating 5 -6 CM

How long does the heating effect last? • Hot Packs - @ depth of 1 CM, 45 -60 minutes

Physiological effects of heat Vasodilatation Vasoconstriction Pain relief Increase tissue extensibility (before ROM) • Increase blood flow • •

WHY DOES BLOOD FLOW INCREASE WITH HEAT? • body attempts to cool hot area • arterioles dilate and more blood comes to the area • skin turns red • blood absorbs the heat and brings hot blood through the rest of the body • cooler blood is returned to the hot area • This reflex may limit the actual heating effect on the tissue you are targeting

(Physiological effects of heat Cont. ) • Promote healing – because of the increase in blood flow • Increase tissue extensibility – Reduction in muscle guarding • Reduces nerve conduction velocity • firing rate of muscle spindle afferents decrease • Golgi tendon organs decrease in activity • result is decrease in spacticity and reflexes.

Effects of Heat on Strength • In 1 st 30 minutes, strength decreases • In next 1 1/2 hour, strength increases • Endurance decreases when heated

Some recent developments • intracavity temp in knee after HP increased significantly and remained high 55 min. • This could increase inflammation in already inflamed arthritic joint • This finding contrary to findings of earlier researchers who believed superficial heat does not raise intraarticular temperatures

So what? • Ice may be more beneficial than heat with inflammatory conditions

Skin Temperature Sensitivity • Skin can tolerate various temperatures depending on the properties of the materials • Some materials such as paraffin have low thermal conductivity • Water - 1050 • Paraffin - 1300 • Fluidotherapy 1180

If you choose to use modalities, you should expect scrutiny from PT’s, peers, others. • Are you applying the modality correctly? – (that’s usually the easy part) • Do you know why you are using the modality? • Are you fully aware of all the contraindications?

Contrast Therapy • Alternating cryotherapy and thermotherapy agents • Results in vasoconstriction & vasodilation of blood vessels in the area • Thought to be a “Pumping” action – stimulates venous & lymphatic return • Effective transition from cold to hot therapy • Use during subacute or chronic phases to remove edema & ecchymosis

Contrast Therapy • Most effective treatment time hasn’t been determined • Commonly used 3: 1 or 4: 1 ratio to equal 20 mins. – 4: 1 C: H 3: 2 C: H 2: 3 C: H 1: 4 C: H • Treatment may end in either hot or cold – depends on the stage of the injury – End in warm – increases tissue temperature for increased stretch and increased activity

Contrast Therapy • This therapy does not significantly influence subcutaneous tissues greater than 1 cm. • Has been shown to increase circulation in both extremities • Unclogs vasculature therefore decreases pain and increases ROM • No need to ever use contrast therapy !!! Common sense & scientific data prohibit its use !!!

Indications for Hot Packs • Pain from muscle tears, ligament strains or sprains • Muscle or tendon tightness • Joint stiffness

Thermotherapy (Heat) – Hydrocollator packs • Treat 20 minutes • 150 -160 degrees – Will burn! Must pad with layered towels or covers!

Hot Packs • Hydrocollator water temperature @ 1600 -1700 • 1 1/2 “ or 6 layers of toweling • Wash towel which touches pt’s skin during treatment • Never lay pt supine on HP’s • 20 min. treatment – story of lengthy HP treatment

Hot Packs Cont. • Which size HP to use • More pts burned HP than with anything else

Thermotherapy (Heat) – Paraffin bath • Great for angular extremities (hands & feet) • 125 -127 degrees • Wash body part • Dip body part 4 -5 times, then wrap in ice bag and towel • Treat 20 -30 minutes • Dispose of wax or return to bath for re-use • Do not use with open wounds

Paraffin Bath • • • Frequently used with arthritis Hand is immobile during treatment Useful when motion is not indicated Paraffin temp - 1300 Have pt wash hands

• Pt dips hand 6 -10 times • While dipping, keep fingers still • Dip quickly, then lift until paraffin stops dripping

• It is mandatory that you check temp. before every use of paraffin bath – if > 1300 don’t use the machine • Wrap in plastic • 10 -20 minute treatment time

• Immersion method also used occasionally – hand dipped to form glove – hand then immersed in paraffin 20 -30 minutes • Where do you put the paraffin after the treatment?

Types of pts who may benefit from paraffin • Arthritis • simultaneous stretch & heat – stiff PIPJ • Conditions where motion is not indicated • Schleroderma

Indications for fluidotherapy • • Joint stiffness Muscle or tendon tightness Spacticity Pain in the hand

Indications for fluidotherapy • • Joint stiffness Muscle or tendon tightness Spacticity Pain in the hand

Fluidotherapy • • • Dry whirlpool treatment Maximum temperature 1180 20 minute treatment Pt can perform ROM during treatment Advantageous when motion indicated Pt should wash hands before treatment

Tips while using fluidotherapy • Machine can be set to preheat every morning • It takes about 20 minutes to preheat • Leave thermostat knob on appropriate temp range. Turning temp knob higher will not make unit heat up faster. • Give pt way to let you know if machine gets too hot (bell)

Tips while using fluidotherapy cont. • Make sure staff monitor temp. of unit. – if > 1180 take the pt out • The manufacturer states that the unit is a sterile environment • Don’t use with open wounds • It needs to be turned up to maximum temp. (1300 ) occasionally to sterilize • After it has been sterilized, be sure to decrease temp. again

• A splint or device to stretch joint can be applied during fluidotherapy

Fluidotherapy Controls • Air speed 0100 • Pulse time – P 1=1 sec on, 1 sec off – P 2=2 sec on, 2 sec off – P 3, P 4, P 5, P 6

Food for Thought • If you have a blood clot in one arm, can you use a heat modality on the other arm?

Light Modalities

Description • Light modalities are found on the electromagnetic spectrum – Most abundant form of energy in the universe • Drying superficial tissues or via superficial photochemical effects • Some mild superficial thermal effects

Types of Therapeutic Lamps • Infrared – Superficial dry heat • Ultraviolet – Heats the body’s tissues for either tissue destruction or therapeutic effects • Visible – Combination of ultraviolet and infrared known as Lasers

Infrared Lamp • Used to dry seeping open wounds or sedate superficial sensory nerves • Radiant modality: An electrical current passes through a carbon or tungsten filament – Intensity controlled by adjusting current flow or distance between lamp and tissue – Constant temperature, increased risk of burns – Heating skin depends on the amount of radiation absorbed • Pigmented, darker skin will absorb more energy and will heat more rapidly than lighter skin

Types of Infrared Lamps • Near-Infrared – Luminous Infrared Lamp – Wavelength: 780 to 1, 500 nm (closest to visible light) – Thermal Effects: 5 to 10 mm deep – Energy formed by carbon and tungsten filament • Light bulb • Some energy is reflected by the surface of the skin

Types of Infrared Lamps • Far-Infrared – Nonluminous Infrared Radiation – Wavelength: 1, 500 to 12, 500 nm – Thermal Effects: < 2 mm • Less penetrating than Near-Infrared – Skin feels warmer – Energy formed by metal coil • i. e. electric stove or space heater • Invisible to human eye

Effects of Infrared Lamps • Constant, dry heat to assist with superficial tissue – Dermatological conditions – Increase cell metabolism – Blood flow – Muscle Relaxation • Contraindications – Any conditions in which other forms of superficial heat are contraindicated

Clinical Applications • Turn On and warm if necessary • Treatment Duration: 20 to 30 minutes • Intensity: adjust wattage or distance of lamp – – Luminous = 24 inches Non. Luminous = 32 inches Inverse Square Law Cosine Law • Clean sweat and dirt, remove jewelry, and fit infrared goggles (if applicable) for patient

Ultraviolet Therapy • Used to produce photochemical reactions in the skin • Wavelength: 180 to 400 nm • 3 UV bands (A, B, and C) produce unique effects

Types of UV • UV-A – AKA: near UV – Effects: Erythema without pigmentation • UV-B – AKA: middle UV – Effects: Erythema without pigmentation, formation of vit D, skin tanning (blister/burn) • UV-C – AKA: far UV – Kills bacteria, formation of vit D, skin tanning

Types of UV Lamps • ‘Hot’ UV Lamps – Low Volt (30 -110 V) High-Amp (5 A) – Electrical current passes through tube, argon gas heats, vaporizing and polarizing mercury to produce UV light in ALL 3 bands and visible violet light • ‘Cold’ UV Lamps – High Volt (3000 V) Low-Amp (15 m. A) – Energy is cooler than ‘Hot’ and produce UV-C

Biophysical Effects • Energy absorbed at a depth between 0. 20 to 0. 22 mm • Damages cell proteins, DNA, & RNA to initiate local inflammatory responses • Effects: – – – Vitamin D synthesis Enhances melanin production Thickens epidermis Superficial vasodilatation Bactericide

Effects of UV Lamps • Wound Healing – Activates inflammatory response – Use: Cold Lamps at intensity of E 3 • Treat Skin Disorders – i. e. psoriasis – Exfoliates tissue and damage DNA that produces the excess skin growth associated with psoriasis – Use: UV-B

UV Contraindications • Sunlight sensitivity • Fair skin (precaution) • Medications or food that increase sunlight sensitivity • Hyperthyroidism

UV Dosage • Determined by Minimal Erythema Dose – Least amount of UV exposure time to produce redness within 1 -6 hrs and disappear within 24 hours • ‘Hot’ Lamps – Determined by each patient and each lamp – Standard distance = 30 in. , not closer than 15 in. • ‘Cold’ Lamps – Standard MED value – 12 -15 seconds at a distance = 1 in.

Determining MED for UV Lamp • Cardboard Test Strips 1. 6 different shapes cut out 2. Use to cover shapes • UV Lamp 30 in. away • Exposes 1 cut out, open the shutters for 30 - sec. , expose the 2 nd cut out and leave the 1 st uncover for the 30 -sec. • Repeat the steps above for the remaining 4 cut outs, but expose them at 15 -sec intervals • Instruct patient to check area every hour and record changes

UV Treatment Dosage • SED – No erythema • MED – Smallest dose that produces erythema within 1 -6 hr • E 1 – Erythema lasts for 1 -3 days, some scaling of skin present, approximately 2. 5 x MED • E 2 – Erythema with edema, peeling, and pigmentation, approximately 5 x MED • E 3 – Severe erythema and burning, blistering, peeling, edema, approximately, 10 x MED

Clinical Application • Calculate treatment dose and duration • Clean area and remove jewelry • Cover skin not being treated (sunscreen if applicable) • Fit UV-resistant goggles to patient and clinician • Position lamp at right angle using the correct distance and duration for each type of lamp • Clean machine and check periodically for maintenance of bulbs

Adjusting the Treatment Dose • Biophysical changes occur with light exposure causing changes in treatment • Duration – 30 to 50% increase for each subsequent treatment – If 3 to 5 minutes, then distance is reduced – 5 to 10 sec is decreased when missing a treatment • Be aware of patients skin color and the lamps distance, duration, and angle

Therapeutic Lasers • • • L=Light A=Amplification by S=Stimulated E=Emission of R=Radiation Classified by the FDA’s Center for Devices and Radiological Health

Production of Laser Energy • Lasers are referred to by the type of active medium (gas, liquid, solid) – He. Ne: visible red light penetrating 0. 8 to 15 mm – Ga. As: invisible penetrating up to 2 cm • Energy is introduced into the active medium • An orbiting electron briefly elevates into a higher or ‘excited’ state • The electron spontaneously returns and releases another photon

Effects of Lasers • Photons are absorbed by tissues to alter molecular-level activity • Theorized to affect pain-producing tissue (muscle spasm), by increasing ATP synthesis that increases cell metabolism and encourages the release of free radicals

Wound Healing • Superficial wounds – Ulcers, surgical insicison, burns • Lasers alter cell membrane permeability and increase in fibroblast, lymphocyte, and macrophage activity occurs • Blood and lymph improve to promote the growth of granulation tissue • Increase collagen and tensile strength of healing wounds

Pain Reduction • Decrease acute and chronic pain • Reduce the rate and velocity of sensory nerve impulses – Similar to cryotherapy but without thermal changes

Fracture Healing • May enhance fracture healing and bone remodeling by increasing capillary formation, calcium deposition, increase callus formation, and reducing hematomas • Photons striking the tissue create acoustic waves that affect bone healing similar to ultrasonic bone growth stimulators

Clinical Application • Because of the investigational status of therapeutic lasers, the clinical application is not described.

Hydrotherapy

Physical Principles • Achieves affects through: • Forces Existing in Water – Buoyancy • Archimedes Principle of Buoyancy – Pressure – Cohesion – Viscosity

Methods of Heat Transfer • Conduction • Convection • Radiation

Biophysical Effects • Thermal Effects – Local and systemic effects • Mechanical Effects – Agitation • Analgesic effects • Counterirritant • Altering agitation

General Description and Unit Operation • • Types of WP Hydrotherapy Area Turbine Whirlpool Care and Safety – Cleaning – Blood-borne pathogens – Electrical Safety

Clinical Indications for Hydrotherapy • Wound Care – How – Whirlpool additives • Exercise Assistance – General Aim – Principle of Exercise in Water – Peripheral Nerves

Hydrotherapy Contraindication/Precautions • Contraindications – Acute Conditions • Gravity dependent position and agitation – Fever • Precautions – – – – Ground fault interrupter Patient should not turn on/off Don’t leave athlete alone Gravity dependent position Do not run turbine dry Do not run turbine with ice still melting Watch for signs of fainting

General Guidelines for Clinical Administration of Hydrotherapy • Preparatory Considerations – ID treatment objectives – Tx temp – Evaluate Athlete – Tx Duration

Warm Whirlpool • Rationale for Use • Treatment – Agitation = 6 -8 inches from segment – Temperature • Arm and hand = 98 -110 • Lower extremity = 98 -104 • Full body = 98 -102 – Tx time • Physiological Considerations • Considerations