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Physical Medicine > 2) Therapeutic Cold & Superficial Heat > Flashcards

2) Therapeutic Cold & Superficial Heat Flashcards

1
Q

PEACE & LOVE

A
  • Protection
  • Elevation
  • Avoid anti-inflammatories
  • Compression
  • Education
  • Load
  • Optimism
  • Vascularisation
  • Exercise
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2
Q

Thermal modalities

A
  • Infrared

- Transfer energy (heat) to or from the tissues

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3
Q

Infrared Modalities

A
  • Wavelengths and frequencies that fall in the infrared portion of the spectrum
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4
Q

Transfer energy (heat) to or from the tissues

A
  • Cooler surface to the warmer surface through the exchange of kinetic energy
  • FOURIER’S Law – The greater the temperature gradient [difference], the more rapid the exchange of energy
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5
Q

Radiation (heat tansfer)

A
  • Transfer of energy without the use of a medium
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6
Q

Evaporation (heat transfer)

A
  • Change from a liquid state to a gaseous state removing thermal energy from the body
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7
Q

Conversion (thermal energy)

A
  • Change from one form of energy to another to have a thermal effect on the body
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8
Q

Cold modalities

A
  • Temperature range between 32°F and 65°F (0°C and 18°C)
  • Local responses to cold application
  • Time between treatment bouts is unclear, ranging from a 1:2 ratio (2 minutes between treatments for every minute ice is applied) to a 1:6 ratio
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9
Q

Local response to cold application

A
  • Vasoconstriction
  • Decreased metabolic rate
  • Decreased inflammation
  • Decreased pain
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10
Q

Skin is in direct contact with the modality = first tissue to lose heat

A
  • As the skin cools, it draws heat from the underlying tissues, adipose tissue, fascia, and muscle in that order.
  • The deeper the tissues, the less cooling that occurs
  • The subcutaneous adipose tissue layer is the greatest barrier to deeper cooling
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11
Q

Cold application sensations

A
  • “Cold” “Stinging” “burning” “aching” and “numbness” [Analgesia]
  • Analgesia -18 to 21 minutes of cold application
  • Patient Compliance
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12
Q

Cold therapy indications

A
  • When the acute inflammatory response is active
  • Before range-of-motion (ROM) exercises (e.g., cryokinetics)
  • After physical activity to reduce cell metabolism
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13
Q

Acute injuries

A
  • Primary physiological effect = the reduction of cell metabolism
  • Limits the amount of secondary injury by decreasing the cells’ need for oxygen
  • Reduces the rate of damaging cellular reactions = decreasing the amount of oxygen the cells require to survive
  • Reducing the cells’ metabolic load = lessens the amount of cellular mitochondrial damage = cell viability
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14
Q

Cold effects on intra-articular injuries

A
  • As the temperature of the skin overlying a joint decreases, the temperature within the joint decreases proportionally
  • r = 0.65
  • Decreasing the skin temperature 10°F (5.6°C) would result in a 6.5°F (3.6°C) decrease in the intra-articular temperature
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15
Q

Cold effects on intramuscular injuries

A
  • Intramuscular temperatures continue to decrease for up to 30 minutes following removal of the modality
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16
Q

Cold application suppresses the inflammatory response by

A
  • Reducing the release of inflammatory mediators
  • Decreasing prostaglandin synthesis
  • Decreasing capillary permeability
  • Decreasing leukocyte/endothelial interaction
  • Decreasing creatine kinase activity
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17
Q

Cold effects on blood and fluid dynamics

A
  • Arteriole vasoconstriction
  • Increased blood viscosity
  • Reduced blood flow
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18
Q

Cold effects on edema formation and reduction

A
  • Reducing cell metabolism → decreasing metabolic activity + limiting the amount of secondary hypoxic injury
  • Cold alone does not promote removal of edema
  • ↑ fluid viscosity = hinder the venous and lymphatic return mechanism
  • Compression + elevation during the cold treatment will ↑ in venous return
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19
Q

Cold effects on nerve conduction

A
  • ↓ the rate that nerve impulses transmitted and ↑ the depolarization threshold required to initiate the impulse
  • Longer cooling times are required to effect changes in deep nerves
  • Superficial nerves will be affected before those nerves that are located deeper within the tissues
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20
Q

Cold effects on pain control

A
  • Primary pain control = removing the chemical and mechanical pain triggers → reducing inflammation and limiting swelling
  • Secondary pain control = interrupting nerve transmission and decreasing nerve condition velocity at the application site
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21
Q

Cold effects on muscle spasm

A
  • Cold reduces muscle spasm by suppressing the stretch reflex by two mechanisms
  • ↑the threshold of afferent nerve endings
  • ↓ the sensitivity of muscle spindles
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22
Q

Cold effects on proprioception and joint position sense

A
  • Changes in nerve conduction velocity of cutaneous sensory nerves and joint receptors interrupt the transmission and perception of pain and may affect proprioception, balance, agility, and/or joint position sense
  • Deficits may last up to 5 to 10 minutes following application
  • Adequate warmup/rewarming
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23
Q

Cryokinetics

A
  • Involves the use of cold therapy in conjunction with movement and is used to improve ROM by eliminating or reducing the element of pain
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24
Q

Cryokinetics allows for

A
  • More pronounced macrophage reaction
  • Quicker hematoma resolution
  • Increased vascular growth
  • Faster regeneration of muscle and scar tissue
  • Increased tensile strength of healed muscle
25
Q

Two factors associated with cryotherapy can increase the risk of cold-related injury during treatment

A
  1. Decreased skin temperature and the amount of pressure used to secure the ice pack (extreme temperatures, those not normally reached during properly applied treatments, can result in frostbite)
  2. Cold and the pressure associated with a compression wrap can traumatize superficial nerves (cold-induced neuropathy – common peroneal nerve)
26
Q

Contraindications to cold therapy

A
  • Circulatory insufficiency
  • Deep vein thrombosis
  • Cold hypersensitivity/Cold urticaria
  • Anesthetic skin
  • Advanced diabetes
  • Chronic wounds
  • Cold-induced myocardial ischemia
  • Uncovered open wounds
  • Peripheral vascular disease
  • Raynaud’s phenomenon
  • Lupus
  • Hemoglobinemia
27
Q

Overview of evidence

A
  • Twenty minutes is used as the default treatment duration for ice packs (and to a lesser extent, 15 minutes has become the standard for ice immersion and 10 minutes for ice massage), but this one-size-fits-all treatment duration limits the effectiveness of cold application
  • The rate, depth, and magnitude of intramuscular cooling is dependent on the thickness of the adipose tissue layer
28
Q

Cold packs various techniques

A
  • Plastic bags filled with cubed, crushed, or flaked ice
  • Reusable cold gel packs
  • Use insulating medium
  • Cold compression therapy (CCT) units
  • Provide 40 mm Hg of compression
  • Chemical (or “instant”) cold packs
29
Q

Cold packs duration

A
  • Cold packs: 20 to 30 minutes, historically
  • More precise method: factor in the target tissues, the depth of those tissues, and if there is overlying adipose tissue
  • Skin numbness can occur in 10 minutes
30
Q

Ice massage

A
  • Use on small, evenly shaped areas
  • Treatment area should only be slightly larger than the face of the ice cup
  • Convenient, practical, and time efficient
  • Causes rapid decline in intramuscular temperature and is effective when treating muscle spasm, contusion, and other minor injuries
  • Does not provide compression
31
Q

Cryostretch

A
  • Combines the effects of cold application and passive stretching
  • “Spray and stretch”
  • Vapocoolant (fluoromethane) spray is used to rapidly decrease skin temperature and reduce pain transmission
  • Combined with simultaneous passive stretching to relieve local muscle spasm to effectively reduce the amount of pain and spasm associated with strains and trigger points
32
Q

Ice immersion

A
  • Placing the body part into a mixture of ice and water having a temperature range of 50°F to 60°F (10°C to 15.6°C)
  • Can be uncomfortable and painful (for 5 minutes)
  • Use a “toe cap” to minimize pain in the fingers and toes
  • Allows for range of motion (ROM) exercises during application
  • Circumferential cooling
33
Q

Whirlpools

A
  • Can be used with hot or cold water
  • Temperature of the immersion depends on the proportion of the total body area immersed
  • Turbine is used to regulate the water flow
34
Q

Physical effects of water immersion

A
  • Buoyancy is used to reduce compressive forces on weight-bearing joints and assist in antigravity motions
  • Resistance to movement is produced by the water’s viscosity
  • Hydrostatic pressure describes the force exerted on a body part immersed in a nonmoving fluid
  • Pascal’s law: the fluid will conform to the irregular surface area and exert an equal pressure across the circumference
35
Q

Heat modalities

A
  • ↑ in molecular vibration + cellular metabolic rate
36
Q

Four primary heat modalities

A
  • Transfer of thermal energy
  • Chemical action associated with cell metabolism
  • Mechanical action as found with therapeutic ultrasound
  • Electrical or magnetic currents as those found in diathermy devices
37
Q

Superficial thermotherapy (heat)

A
  • Heats a larger area of tissue (the skin), but its limited depth of penetration reduces the overall volume of tissue heated
  • Limited to depth of 2 cm
38
Q

Deep thermotherapy (heat)

A
  • Deep-heating agents = therapeutic ultrasound and short-wave diathermy are capable of heating tissues located at depths greater than 2 cm
39
Q

Thermotherapy (heat) indications

A
  • Control the inflammatory reaction in its subacute or chronic stages
  • Encourage tissue healing
  • Promote venous drainage
  • Reduce edema and ecchymosis
  • Improve ROM before physical activity or rehabilitation
40
Q

Temperature gradient [difference]

A
  • Causes the modality to lose heat and the body to gain heat
41
Q

Maximum therapeutic benefits occur when the skin temperature rapidly increases

A
  • Increasing the excitability of local temperature receptors that cause an active release of vasoactive mediators
42
Q

If the intensity of treatment is too great or if the duration of exposure is too long, burns will result

A
  • Mottling of the skin is a warning sign that tissue temperatures are rising to a dangerously high level
43
Q

Tissue rewarming

A
  • Skin and subcutaneous adipose tissue temperatures rapidly decrease following the removal of the heating agent
  • Heat is lost to the surrounding air, and the increased circulation continues to deliver relatively cool blood to the treated area while the venous system removes relatively warm blood
  • Superficial intramuscular temperatures remain elevated for approximately 30 minutes following the conclusion of the treatment
44
Q

Effects on the injury response process

A
  • Primary effects: ↑ cell metabolism and rate of inflammation, both require ↑ oxygen
  • If applied too soon in the injury response process,
    ↑ cell metabolism = ↑ the number of cells injured or destroyed because of hypoxia
  • ↑ the inflammatory rate could extend the acute and subacute inflammatory stages
45
Q

Heat’s effects on cellular response

A
  • = tissue temperature to rise
  • ↑ cellular metReciprocal relationship
  • ↑ temperature = ↑ in cellular metabolic rate
  • ↑ in cell metabolism abolic rate = arteriolar dilation + increased capillary flow
  • For each increase of 18°F (10.0°C) in skin temperature, the cell’s metabolic rate ↑ by a factor of two to three [Q10 Effect]
46
Q

Heat’s effects on inflammation

A
  • Heat accelerates inflammation
  • Soft tissue repair is facilitated through an accelerated metabolic rate and increased blood supply → encourages the removal of cellular debris and increase delivery of the nutrients necessary for the healing of tissues
  • ↑ oxygen delivery (stimulates the breakdown, removal of tissue debris, inflammatory metabolites)
  • Increase in the delivery of leukocytes = encourages phagocytosis
47
Q

Heat’s effects on blood and fluid dynamics

A
  • Blood flow increases soon after heat application
  • Vasodilation occurs
  • Viscosity of blood decreases
48
Q

Heat’s effects on edema formation and reduction

A
  • Limb volume increases, especially when the limb is in a gravity-dependent position
  • Edema increases however the capability of removal is greater
  • Increased capillary pressure forces edema and harmful metabolites from the injured area
49
Q

Heat’s effects on nerve conduction

A
  • ↑ rate of chemical reactions and cell metabolism = in ↑ nerve conduction velocity.
  • Both sensory and motor nerve function are typically enhanced through heat treatments
49
Q

Heat’s effects on nerve conduction

A
  • ↑ rate of chemical reactions and cell metabolism = in ↑ nerve conduction velocity.
  • Both sensory and motor nerve function are typically enhanced through heat treatments
50
Q

Heat’s effects on pain control

A
  • ↓ mechanical pressure on nerve endings
  • ↓ muscle spasm
  • Resolving ischemia
  • Counterirritant effect via a descending pain control mechanism that increases the pain threshold
51
Q

Heat’s effects on muscle spasm and function

A
  • ↓ the threshold of muscle spindles

- ↓ fluid viscosity + ↑ nerve conduction velocity + ↑ rate of Golgi tendon organ firing = ↑ muscle function and strength

52
Q

Heat’s effects on tissue elasticity

A
  • When collagen-rich tissue such as tendon, muscle, and fascia is heated to 104°F to 113°F (40°C to 45°C) for 5 minutes, it can be physically elongated (plastic deformation)
  • Tension is necessary to elongate muscle and capsular tissues
53
Q

Exercise as a heating agent

A
  • Moderate to intense exercise ↑ intramuscular temperatures approximately 4°F (2.2°C) at a depth of 5 cm in the involved muscles
  • Although active exercise does not result in vigorous heating of the muscle, moderate heating occurs over a larger cross-sectional area and deeper into the muscle than most other forms of heat
54
Q

Contraindications and precautions to heat application

A
  • Acute injuries
  • Neurovascular deficits
  • Sleeping or unconscious patients
  • Thrombophlebitis
  • Patients with tumors
  • Closed infection
  • Pregnancy
  • History of cardiac failure
  • Hypertension
55
Q

Moist heat packs

A
  • Canvas pouch filled with silica or a similar substance capable of absorbing a large number of water molecules (variety of shapes and sizes)
  • Maintained at a constant temperature ranging between 160°F and 166°F (71.1°C to 74.4°C)
  • Layer around the heat pack to insulate heat pack and protect skin
56
Q

Paraffin bath

A
  • Mixture of wax and mineral oil (7:1 ratio) used for delivering heat to small, irregularly shaped areas, such as the hand, fingers, wrist, and foot
  • Melted paraffin temperature; Lower extremity: 113°F to 121°F (45.0°C to 49.4°C)
  • Refer to the manufacturer’s maintenance requirements for proper maintenance
57
Q

Fluidotherapy

A
  • Air jets circulate heated cellulose particles that have a lower specific heat and thermal capacity than water (higher treatment temperatures)
  • Convective modality that delivers dry heat to the extremities
  • Patient inserts the body part into the unit through one of the portals located on the machine (clinician’s hands can also be inserted into the unit to assist with ROM exercises or perform joint mobilization techniques)
58
Q

Contrast therapy

A
  • Alternating hot and cold treatments (stationary water immersion, tandem whirlpools, moist heat packs and ice packs)
  • Causes a cycle of vasoconstriction and vasodilation of the superficial blood vessels
  • Commonly used ratios are 3:1 and 4:1 (hot to cold)
  • 1:1, 2:1, 3:1, 4:1, and 5:5

Physical Medicine (5 decks)

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