Thermotherapy

1. 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

2. 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

3. Cellular & Blood/Fluid Responses • Cellular – •  temperature   cell metabolism   O2; cell waste  excreted •  temperature  blood hemoglobin releases O2 (106°F = twice as much O2 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

4. 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

5. 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

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

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

8. 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)

9. 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

10. 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

11. 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

12. 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 (1st 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

13. 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.

14. 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

15. 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 Heat penetrates into tissue Ultrasound Depth of heating 5-6 CM Superficial Vs. Deep Heat

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

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

18. 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

19. 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. (Physiological effects of heat Cont. )

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

21. 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

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

23. 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 Skin Temperature Sensitivity

24. 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?

25. 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

26. Contrast Therapy • Most effective treatment time hasn’t been determined • Commonly used 3:1 or 4:1 ratio to equal 20 mins. • 4:1 3:2 2:3 1:4 C:H C:H C:H 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

27. 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 !!!

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

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

31. 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

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

33. 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

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

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

36. 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

37. 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?

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

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

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

41. 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

42. 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)

43. 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

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

45. Fluidotherapy Controls • Air speed 0-100 • Pulse time • P1=1 sec on,1 sec off • P2=2 sec on, 2 sec off • P3, P4, P5, P6

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

47. Light Modalities

48. 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

49. 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

50. 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