Superficial Hot & Cold Flashcards
53 y.o. patient who is 4 weeks s/p colles fracture of the right wrist. The cast has been removed earlier this week and the patient is now in a wrist brace. Wrist ROM is limit and mild yet noticeable edema is present in the wrist and hand.
****Hot Pack: I would want to use a lightweight hot pack on the client’s wrist (being careful to pay attention to the pressure being put on the healing wrist - I don’t want the weight of the pack to cause more pain or damage.) I would want the client to be sitting upright, in a stable chair, with their arm supinated on a firm surface (preferably on top of some padding, for comfort - maybe like the plinths we use in lab, as opposed to a wooden desk?). I would definitely place at least 3 layers of padding between the skin and the hot pack cover (collar shaped, to cover the entire wrist), and would add more if there was hypersensitivity to the heat. The hot pack would increase vascularity and would decrease stiffness in the surrounding soft tissue prior to passive stretching. The covered hot pack is between 104-113 degrees (F), and is typically left on for 15-20 minutes (although I would err on the side of caution and stay closer to 15 and gradually add more time, depending on the client’s comfort level.) (Briana Friel) This is a great selection. I like that you would be checking the skin integrity and patient’s response to the modality frequently. The heat would assist in elongating tissue within the treatment portion of the program (SRS). I would assume that the pack was new (and therefore equivalent to 3 layers - an older pack would be equivalent to 2 layers and I would add more toweling.) I’m not sure about scaly/dry skin - would I want to moisturize it beforehand and then provide additional toweling, since the skin is more fragile? Yes, that is a good idea…you could also use a bit of lotion after. Think how wonderful it is to put a moisturizer on then open the pores with a bit of heat..that will do much for the dry skin. (NR)
other option:
Paraffin: I would chose paraffin because it provides an even distribution of heat and the mineral oil improves joint fluidity. Before using paraffin, I would make sure the client does not have impaired sensation, inflammation, or malignancy. I would be careful if the client had a DVT, infection, cardiac disease, RA and an impaired mental status. I would ask the client to remove all jewelry from their wrist and hands, and instruct them to wash and dry hands throughly. Dry hands is key so the moisture does not cause burns.YES! so important. After checking the temperature to make sure it is between 118 and 135 degrees, I would instruct the client to place their hand in the wax far enough so that it covers about one forth of their forearm, and then remove it. Once the wax is dry (not shiny), I would instruct them to repeat the process 8-10 times. Once completed, I would wrap their hands in plastic wrap, and wrap a towel around to keep the heat in for about 20 minutes. Overall, paraffin treatments will help the clients functioning improve during therapy. (Rebecca) Very well thought out! This is a great form of deep heat that would allow greater tissue extensibility during therapeutic activities.(SRS)
65 y.o. with history of osteoarthritis both hands for past 5 years. No evidence of edema. She is experiencing an exacerbation of her pain symptoms but acute inflammation has subsided. She is referred for OT for pain relief, activity adaptation, and instruction in home exercise program…
**Paraffin Bath. I would choose Paraffin because the client is experiencing pain with their osteoarthritis in her hands, a paraffin bath with help by evenly distributing around the joints in the hands with hot wax and mineral oil to improve joint fluidity. To use the Paraffin I would make sure that the client does not have any hypersensitivity to heat, open wounds, or other contradictions and precautions with heat they may have. After the client removes any jewelry and washes and completely dries their hands (yes this is so important cause moisture between fingers can burn patient. I generally coach them to dry into finger web spaces and give them a cloth towel instead of a paper towel as they are more effective) they can begin use of the Paraffin bath and temperature should be checked by the therapist prior to use on client. I would have the client begin by dipping their hands in the Paraffin bath one at a time, the temperature can be from 118- 135 degrees Fahrenheit. They dip their hand in twice, first they dip hand in once pull it out wait for the shiny appearance to go away so that it is hardened and then dip again. After repeated 8-10 times (each time waiting for the glossiness to go away!) put hands in plastic bag (or saran wrap) with a towel wrapped around to keep in heat. Keep the bags on with the wax on for about 20 minutes and then pull it off. The hands need to stay still during this process so the disadvantage is there is not a lot of mobility during this process. Paraffin can be used with a hot pack for more heat and also with passive stretch. Paraffin bath can help improve function therefore during therapy I can teach home exercises and activity adaptations and the client could more actively engage. (Lea R.) Nice Lea. (NR)
option 2
Fluidotherapy: Fluidotherapy is the dry version of the whirlpool and could be used to benefit this patient. Applying heat to this patient would be beneficial as it will help to reduce pain and has the ability to loosen the muscles that are heated up which can help with stretching and AROM. Prior to the patient arriving you would want to heat up the Fluidotherapy machine to between 105 and 118 degrees. A patient can tolerate 118 degrees because dry heat is tolerated at higher levels. A drawback to having such high heat is that the patients skin many become dry when using fluidotherapy. Inside of the machine are small particles called cellulose that are moved around using hot air. This modaility is the only exception in which you would use a wheely chair as the Fluidotherapy machine can not be adjusted to the patient . You would keep the patient in the machine for 15-20 minuets. In the Fluidotherapy machine the patient can actively exercise her hands as the tissues warm up and the therapist can easily access the patient to assist with active-assistive and passive mobilization. (Allison) Nice. For this modality you also want to make sure the patient does not have a respiratory condition that couldn’t tolerate the flying wisps of dust that happens from all the heat and air blowing. I usually throw a towel over the top to keep the dust from flying (it also helps to heat up faster.
64 y.o. who strained his rotator cuff during a golf tournament one week ago. Initial evaluation reveals the right shoulder is painful and weak. In your post be sure discuss how you would position the client and where you would place the modality
**Hot packs: I would choose this because it is a relatively large area and I want to provide heat to reduce pain symptoms and promote relaxation (analgesic effect). Heat also helps with decreasing muscle spasm and spasticity (vascular effects), aids tissue repair (metabolic effects), and tissues are more easily stretched after heating (connective tissue response). I would do the treatment for 20 min with the patient laying supine with propped elbow on pillow to keep in line with the shoulder. I would place the hot pack wrapped in padding with a towel on the shoulder and tuck under the scapular region. I am looking for the patient to experience heat that allows for stretch and elevation but not movement of the muscles and tendons. Jen K.
Nice, Jen. Remember you need 6-8 layers of toweling. Also if the client is very large and the heat only goes 1-2 cm consider how effective the hot pack may be (in these cases you might want to warm up aerobically). Folks tend to be less comfortable in supine and although you could do this you would want extra toweling where the client is laying on the hotpack and be sure to ask the client if they have back problems (80% of people do at one time in their life) and if so place a pillow or bolster under their knees. You can also have the client put head on a pillow on a table top, or my favorite (if they have abduction) sitting, side near table top with elbow propped on pillow on tabletop. We’ll try these in lab. (NR)
option 2
Cold Pack: I would use this modality on the client’s right shoulder. While something like a cryocuff would be easier to hold in place, the client would most likely not have one in his home so a cold pack would be more readily available for him to use after a treatment session if needed. With this in mind, I would be able to show him the proper placement and amount of time to use it so that if he needed to use a cold pack when he was not at treatment, he would know what to do. I could also give him information on how to make a homemade one or incorporate household products such as a bag of frozen peas as well if he did not have a cold pack at home. Using this modality would be beneficial because it would produce an analgesic effect, meaning a decrease in pain symptoms. Cold therapy such as an ice pack can also be helpful in that it can control inflammation and edema in the early stages of healing. For this treatment, I would make sure that my patient was in a comfortable position. I would place him in a chair (without wheels on the bottom for safety reasons) that was next to a table so that his arm could rest on a pillow at an appropriate level. I would place a towel under the cold pack so that it would not be directly on his skin.towel may be a little thick unless you wet it…if dry use a pillow case or paper towel. I would say that this cold pack treatment could be used for about 5-15 minutes (you hearty athlete types can handle 15 min but for a 64 year old that might be cruel), but I would monitor the patient in case he was experiencing any discomfort due to the cold. (Carly V.) Nice practical thoughts here! Clearly a modality you are comfortable with… (NR)
20 y.o. college tennis player diagnosed with lateral epicondylitis. Symptoms have been present for four weeks. You are asked to provide soft tissue release, stretching and isometric strengthening. The client continues to play tennis. In your post you choose modality use in the clinic, after or before practice or game. Your rationale should include identification of the phase of healing for this individual.
***Hot pack: I would use a hot pack on this pt. because heat increases the soft tissue to about a 1-2 cm depth. Yes, and think how superficial that lat epi is! The heat lasts about 20 minutes after the treatment allowing for stretching and isometric strengthening within that time period. The analgesic effect will help to decrease pain which will help the pt. with both stretching/strengthening and the continuation of tennis. Before applying the hot pack I would first place it in a hot pack cover, in this case I would use the collar shaped cover because it would be the best fit for the elbow. When applying the hot pack I would make sure to use 6-8 layers of towels to be safe (depending on pts. layers and how new/old the hot pack covers are). The pt. can either be prone or sitting on a plinth or seated on a stable chair while the hot pack is being applied, depending on the clinic or pts. preference. I would make sure the temp of the water should be 165-170 degrees so the hot pack ends up being between 104-113 degrees when applied, and keep on the pt. for 15-20 minutes. (Melissa). Wow, really nice info. I would more likely use this before playing tennis. It would warm the tissue up…by the time the 20 min passed the bodies own aerobic activity would keep the muscle warm. This is another point… often you can use aerobic activity to warm a muscle up and just skip the hotpack! (ie. an UE arm bike) (NR)
option 2
Ice Massage: I believe that this would be an effective modality for the pt. 24-48hrs after he participates in games. While his injury is 4 weeks old and would not be consider acute, his participation in tennis would cause an acute re-injury to the area.yes! I would select an ice massage because it would allow the focus to be placed specially on the affected area. Before applying the ice massage in order to decrease pain and spacticity post exercise, I would have the pt. seated with their affected arm ABD to 90 degrees (or maybe not quite as extreme at 45 as it may be uncomfortable to be at 90) and supported by the table or a towel for comfort. Ice massage combined with this elevated position would allow for a greater edema reduction. Good idea to consider elevation with a client who has edema, however this is very minor edema and elevation may not have huge effects but if you wanted to elevate you might consider laying on back with arm elevated on a pillow…maybe more comfortable than 90 degrees ABD although since this is a young athlete your way may be fine) When applying the ice massage I would first apply gel to the targeted area, then with an ice wand I would slowly massage the affected area in small circles, and maintain direct contact with the skin. I would inform the pt. of the stages of cold: cold, burning, achy, and numb. I would then massage for x2-5 minutes or until the pt. reported loss of sensation. After completion of this modality the pt. should be better prepared to participate in stretching and strengthening activities. I may also provide pt. eduction on how to independently complete this modality using an ice block in a Styrofoam cup without gel after his matches or practice to help aid in healing. (Kristin L.) Nice home tip…and even an ice cube and paper towel to hold it works in a pinch. (NR)
46 y.o. secretary presents with decreased mobility and difficulty turning head to the right due to stiffness of SCM and scalenes. Identify rationale for treatment choice, positioning of client and placement of modality include (right or left)
Hot pack- I believe a hot pack would be a good modality to use with a cervical strain because it will warm up the stiff SCM and scalenes for the patient. This will be a good way to warm up the muscles prior to stretching. The heat will help with pain relief, muscle tension, and muscle spasms that may be occurring. I would position the patient supine on a plinth, with a cervical shaped hot pack strapped around the neck (making sure to warm the whole cervical area). I would make sure to add 3 layers of towel in addition to the cover, which counts as 3 layers. Laying supine with a pillow under the head for support will allow the cervical area to relax, and if necessary and available, for comfort adjust the angle of incline on the plinth. For increased comfort I would recommend a wedge under the knees to avoid stress on the low back. The hot pack should stay on for 15-20 minutes. (Biz). Nice thoughts, Biz. You are trying to relax the muscle on the left side which is the side that is stiff. Certainly heating up the entire cervical is nice but I may pay close attention to the left side forming snuggly. If the client is lying on their back as you describe they are putting pressure on the hotpack which will instensify the heat so you would need extra toweling. With the heat so close to the earlobes be sure to make sure the hotpack is toweled well there. Another and maybe better option would be to have the client prone with face in a face hole or sitting with arms up on table and head on pillow. We will do this in lab so you can see. (NR)
option 2
Ice Pack: I believe applying an ice pack to the patient is a good modality to use because it seems the patient is in the acute phase of her injury which is 24-48 hours after the injury occurred. Applying an ice pack will promote vasoconstriction which is narrowing of the blood vessels this will control inflammation that is causing pain. Spasticity of the SCM and scalene muscles will also decrease because the cold affects the muscle spindle’s reaction to stretch. Before applying the cold pack I would make sure the client doesn’t have history of poor sensation or cold sensitivity or any other contraindications. I would wrap the cold pack in a pillow case or towel because you don’t want to apply it directly to the skin. The patient would be directed to lay supine on a plinth with the cold pack in a pillow case placed on the left side of the patient’s cervical area for 15-20 minutes. I would make sure to not apply the cold pack over 20 minutes. (Kelsey T.) Great thoughts Kelsey. Although most won’t tolerate more than 15 min and often 10 is absolutely long enough. See Biz answer about your positioning. (NR)
