Thermal Agents Cold

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Thermal Agents Cold

  1. 1. Thermal Agents: Cryotherapy KIN 195
  2. 2. Basics of Heat <ul><li>Heat: a term used to describe the energy that matter can store in the form of electronic, atomic, or molecular motion. </li></ul><ul><ul><li>The great the molecular motion, the greater the heat production </li></ul></ul>
  3. 3. Basics of Cold <ul><li>Cold: in a physical sense is a negative condition, depending on the decrease in the amount of molecular vibration that constitutes heat. The less the molecular motion, the less heat production. Thus, a sensation of cold results. </li></ul>
  4. 4. Temperature: <ul><li>Temperature is a measure of the average amount kinetic energy possessed by an individual molecule of a body (kinetic theory of heat). </li></ul><ul><ul><li>Temperature is a measure of sensible heat of cold in a body. </li></ul></ul><ul><ul><li>Temperature is expressed as Fahrenheit or Centigrade. </li></ul></ul>
  5. 5. Classification of temperatures: for treatment purposes, are classified as follows:
  6. 6. Transfer of energy: heat, or the loss of hear, occurs in any of the following ways: <ul><li>Conduction: Contact </li></ul><ul><li>Convection: movement </li></ul><ul><li>Evaporation: through liquid-gas transfer </li></ul><ul><li>Radiation: electromagnetic waves </li></ul><ul><li>Conversion: transfer from one energy type to another </li></ul>
  7. 7. Factors in heat transfer Cont <ul><li>Conductivity: the power of transmitting heat, electricity or sound. A tissue’s conductivity is usually dependent on the water content; the higher the water content the better the conductivity </li></ul><ul><ul><li>Muscle - 72-75% water and conducts well </li></ul></ul><ul><ul><li>Bone and skin are 5-16% water and poor conductors </li></ul></ul>
  8. 8. Factors in heat transfer Cont <ul><li>Resistance: the tissues opposition to the passage of energy </li></ul><ul><ul><li>Expressed in Ohms. </li></ul></ul><ul><ul><ul><li>Bone and fat have high resistance </li></ul></ul></ul><ul><ul><ul><li>Muscle and Skin low </li></ul></ul></ul>
  9. 9. Cryotherapy <ul><li>Used to describe the application of cold modalities that have a temperature range between 32° and 65° F </li></ul>
  10. 10. Cryotherapeutic Benefits <ul><li>To obtain therapeutic benefits </li></ul><ul><ul><li>skin temp. must be reduced to 57 °F for optimal decrease in local blood flow </li></ul></ul><ul><ul><li>skin temp must be reduced to 58°F for analgesia </li></ul></ul><ul><ul><li>Skin temperature must be reduced to 36°F to produce intra-articular temp. changes in the knee </li></ul></ul><ul><ul><ul><li>The temp of the skin over a joint decreased the temp in a joint proportionally 10° F skin 6.5° F joint </li></ul></ul></ul>
  11. 11. Effects of Cold on Application Site <ul><li>Vasoconstriction </li></ul><ul><li>Decreased Rate of Cell metabolism resulting in a decreased need for oxygen </li></ul><ul><li>Decreased production of cellular wastes </li></ul><ul><li>Reduction of inflammation </li></ul><ul><li>Decreased Pain </li></ul><ul><li>Decreased Muscle Spasm </li></ul>
  12. 12. Systemic Effects of Cold Exposure <ul><li>General vasoconstriction in response to cooling of the posterior hypothalamus (this happens with a .2°F drop of circulating blood) </li></ul><ul><li>Heart rate is decreased </li></ul><ul><li>Respiration Decreases </li></ul><ul><li>Shivering and increased muscle tone </li></ul><ul><ul><li>If core temperature continues to drop this is the body’s response to increase heat </li></ul></ul><ul><ul><li>IN GENERAL THIS DOES NOT OCCUR WITH THERAPEUTIC ICE APPLICATION! </li></ul></ul>
  13. 13. The Effects of Ice on Injury Response <ul><li>Indications </li></ul><ul><ul><li>Acute injury or Inflammation </li></ul></ul><ul><ul><li>Acute pain </li></ul></ul><ul><ul><li>Small 1st degree burns </li></ul></ul><ul><ul><li>Post-surgical pain and edema </li></ul></ul><ul><ul><li>In conjunction with rehab ex. </li></ul></ul><ul><ul><li>Neuralgia </li></ul></ul><ul><ul><li>Acute or chronic muscle spasm </li></ul></ul><ul><ul><li>Spasticity accompanying CNS disorders </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Cardiac or Resp. involvement </li></ul></ul><ul><ul><li>Uncovered open wounds </li></ul></ul><ul><ul><li>Circ. Insufficiency </li></ul></ul><ul><ul><li>Cold Allergy </li></ul></ul><ul><ul><li>Anesthetic Skin </li></ul></ul><ul><ul><li>Advanced Diabetes </li></ul></ul><ul><ul><li>Raynaud’s Phenomenon </li></ul></ul>
  14. 14. Raynaud's Phenomenon <ul><li>A vascular reaction to cold application or stress that results in a white,red, or blue discoloration of the extremities. The fingers and toes are the first to be affected </li></ul><ul><ul><li>Raynaud's phenomenon is a condition resulting from poor circulation in the extremities (i.e., fingers and toes).  In a person with Raynaud's phenomenon, when his or her skin is exposed to cold or the person becomes emotionally upset, the blood vessels under the skin tighten and the blood flow slows </li></ul></ul><ul><ul><li>This happens because the blood vessels under the skin tighten.  When blood does not reach parts of the body, these areas may turn blue and feel cold. </li></ul></ul>
  15. 15. Physiological Effects of Cold: Metabolic <ul><ul><li>Decreased secondary cell deaths by hypoxia (swelling prevents oxygen from reaching cells). The decrease in metabolism allows them to live without as much oxygen. </li></ul></ul><ul><ul><li>Normal body temperature is 37 ° C. </li></ul></ul><ul><ul><li>Increase above 45° C (113° F) proteins denature </li></ul></ul>
  16. 16. Physiological Effects of Cold: Metabolic <ul><ul><li>Reduction of edema through decreased capillary hydrostatic pressure and decreased permeability and osmotic pressure </li></ul></ul><ul><ul><li>Increase blood viscosity (make it thicker so it won’t flood the area as quickly) </li></ul></ul><ul><ul><li>Decrease in chemical mediator effectiveness (they cause vasodilatation) </li></ul></ul>
  17. 17. Metabolic Effects of Cold <ul><ul><li>Hypothesis: Decreases below 58 ° F cause a “hunting” response (Lewis 1932) to occur </li></ul></ul><ul><ul><ul><li>Proposed mechanism: Histamine like release increases vasodilatation as a self defense response </li></ul></ul></ul><ul><ul><li>Knight & Draper, Chapter 13, beginning on p.220 examines the facts and fallacies of Cold-Induced Vasodilation, including: </li></ul></ul><ul><ul><ul><li>CIVD doesn’t increase blood flow post cryotherapy </li></ul></ul></ul><ul><ul><ul><li>Cryotherapy facilitates return to exercise & improves progress (as well as decreasing pain & spasm) </li></ul></ul></ul><ul><ul><li>Don’t go below 58 ° F and keep time shorter than 30 minutes to be on the safe side </li></ul></ul>
  18. 18. Physiological Effects of Cold: Pain <ul><li>Local decrease in free nerve ending sensitivity </li></ul><ul><li>Increases the threshold for nerve firing </li></ul><ul><li>Slows synaptic activity </li></ul><ul><li>Allows disruption of pain-spasm-pain cycle via analgesia </li></ul>
  19. 19. Physiological effects of cold: Hemodynamic <ul><ul><li>Vasoconstriction from smooth muscle in arterioles </li></ul></ul><ul><ul><li>reflex vasoconstriction from A-delta (spinal reflex to preserve body heat) </li></ul></ul><ul><ul><li>Cold blood hits hypothalamus and may start shivering response if cold enough </li></ul></ul><ul><ul><li>A small amount of vasoconstriction gives a 4 fold decrease in blood flow </li></ul></ul>
  20. 20. Muscle Activity <ul><li>Decreased muscle spasm by decreasing muscle spindle activity. </li></ul><ul><li>Intramuscular fibers (muscle spindle) runs parallel to fibers of the muscle. Muscle contraction causes spindle contraction so it remains sensitive. The lower the temperature, the lower the spindle activity. </li></ul>
  21. 21. RICES: Rest, Ice, Compression, Elevation, Stabilization <ul><li>RICES serves to counteract the body’s initial response to injury </li></ul><ul><ul><li>Rest limits scope of original injury by preventing further trauma </li></ul></ul><ul><ul><li>Ice can decrease cell’s metabolism, reducing the amount of secondary hypoxic injury by enabling tissues to live on limited oxygen and secondarily reduce pain </li></ul></ul><ul><ul><ul><li>Crushed ice is the ideal form of cold application during initial injury because it produces the most rapid temp. decrease. </li></ul></ul></ul>
  22. 22. RICES: Rest, Ice, Compression, Elevation, Stabilization, cont. <ul><li>Compression - </li></ul><ul><ul><li>decreases the pressure gradient between blood vessels and tissue and discourages further leakage from capillaries. </li></ul></ul><ul><ul><li>Also Encourages Lymphatic drainage </li></ul></ul><ul><ul><li>Compression Types </li></ul></ul><ul><ul><ul><li>Circumferential - provides even pressure </li></ul></ul></ul><ul><ul><ul><li>Collateral - Pressure on 2 sides (aircast) </li></ul></ul></ul><ul><ul><ul><li>Focal Compression - U-shaped horseshoe pads </li></ul></ul></ul>
  23. 23. RICES: Rest, Ice, Compression, Elevation, Stabilization, cont. <ul><li>Elevation </li></ul><ul><ul><li>Decreases the hydrostatic pressure within the capillary beds to encourage absorption of edema by lymphatic system </li></ul></ul><ul><ul><li>This has the greatest effect at 90° perpendicular to the ground </li></ul></ul><ul><ul><ul><li>at 45 ° the effect of gravity is 71% comparatively </li></ul></ul></ul><ul><li>Stabilization </li></ul><ul><ul><li>Limits muscle spasm & neural inhibition related to guarding the injured area </li></ul></ul><ul><ul><li>Early stabilization eases the pain-spasm-pain cycle by letting the muscles relax </li></ul></ul>
  24. 24. Cryokinetics <ul><li>The use of cold in conjunction with movement </li></ul><ul><ul><li>Used to decrease pain and allow for free motion through the normal ROM </li></ul></ul><ul><ul><li>Results in more pronounced macrophage reaction, quicker hematoma resolution, increased vascular growth, faster regeneration of muscle and scar tissue </li></ul></ul><ul><ul><li>“ The purpose of cold applications post-immediate care is to facilitate pain-free exercise. Injury pain & muscle spasm are decreased, allowing exercise to begin earlier & progress faster” (Knight & Draper, p. 227) </li></ul></ul><ul><ul><li>Exercise is the key to rehab. Without proper ther ex, Cryotherapy will actually hinder rehab (p.228) </li></ul></ul>
  25. 25. Penetration depends on many factors: <ul><li>Cold has a longer wavelength than heat </li></ul><ul><li>Local temperature gradient </li></ul><ul><li>Treatment surface area covered </li></ul><ul><li>thickness and characteristics of tissue treated (fat is an insulator, tissues with high water content have better heat transfer) </li></ul>
  26. 26. Clinical Application <ul><li>Cold Pack </li></ul><ul><li>Ice Massage </li></ul><ul><li>Ice Immersion </li></ul><ul><li>Cryostretch </li></ul><ul><li>Whirlpools </li></ul>
  27. 27. Cold Packs <ul><li>Ice Bags, </li></ul><ul><li>Reusable Cold Pack </li></ul><ul><li>Instant Cold Back </li></ul><ul><li>Tx time for all are 15-30 minutes </li></ul><ul><ul><li>Because of lasting effects application should be no less than 2 hours apart </li></ul></ul><ul><ul><li>For controlled Cold Therapy Units - may be applied continuously for 24 to 48 hours post acute injury or surgery </li></ul></ul>
  28. 28. Cold Packs <ul><li>Indications </li></ul><ul><ul><li>Acute injury (may use with wet wrap) </li></ul></ul><ul><ul><li>Acute or Chronic Pain </li></ul></ul><ul><ul><li>Postsurgical Pain and Edema </li></ul></ul><ul><ul><li>Shape of Body part </li></ul></ul><ul><li>Precautions </li></ul><ul><ul><li>AC joint and other areas may not be suitable for wet wrap </li></ul></ul><ul><ul><li>Tension of elastic wrap should be enough to provide adequate compression without unwarranted pressure </li></ul></ul><ul><ul><li>Ensure Circulation w/wrap </li></ul></ul><ul><ul><li>Frostbite - chance for reoccurrence </li></ul></ul><ul><ul><li>over large or superficial nerves </li></ul></ul>
  29. 29. Ice Massage <ul><li>Appropriate for delivering cold tx to small evenly shaped areas. </li></ul><ul><li>Most effective for muscle spasm, contusion and other minor well-localized areas </li></ul><ul><li>Duration of tx </li></ul><ul><ul><li>5-15 minutes or until ice runs out </li></ul></ul><ul><ul><li>if the purpose is analgesic, then stop when numb </li></ul></ul>
  30. 30. Ice Massage <ul><li>Indications </li></ul><ul><ul><li>Subacute inflammation or injury </li></ul></ul><ul><ul><li>Muscle strain </li></ul></ul><ul><ul><li>Contusion </li></ul></ul><ul><ul><li>Acute or chronic pain </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>All other ice contraindications </li></ul></ul><ul><ul><li>When pressure is not warranted </li></ul></ul><ul><ul><li>Suspected Fx </li></ul></ul><ul><li>Precuations </li></ul><ul><ul><li>Injuries where pressure massage may be contraindicated </li></ul></ul>
  31. 31. Ice Immersion <ul><li>Temp. 50° - 60 ° F </li></ul><ul><li>Time 10-20 min. </li></ul><ul><li>Indications </li></ul><ul><ul><li>Acute Injury or Inflam. </li></ul></ul><ul><ul><li>Acute or Chronic Pain </li></ul></ul><ul><ul><li>Post surgical pain </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Same as general ice Contraindications </li></ul></ul><ul><ul><li>Acute injury where gravity is contraindicated </li></ul></ul>
  32. 32. Cryostretch <ul><li>“ Spray and Stretch” using vapocoolant </li></ul><ul><li>Traditionally preformed with ethyl chloride due to its ability to quickly evaporate and cool superficial tissue </li></ul><ul><li>This technique is used as a counterirritant </li></ul><ul><ul><li>simply masks the symptoms to allow for a stretch </li></ul></ul>
  33. 33. Cryostretch <ul><li>Precautions </li></ul><ul><ul><li>Can Cause frostbite </li></ul></ul><ul><ul><li>Ethyl Chloride is extremely flammable </li></ul></ul><ul><ul><li>Ethyl Chloride is a local anesthetics but if inhaled can become general </li></ul></ul><ul><ul><li>It’s use is based on tradition rather than fact </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Allergy </li></ul></ul><ul><ul><li>Open wounds </li></ul></ul><ul><ul><li>Post/surgical </li></ul></ul><ul><ul><li>Eyes </li></ul></ul><ul><ul><li>All other cold & passive stretch contraindications </li></ul></ul><ul><li>Indications </li></ul><ul><ul><li>Trigger points </li></ul></ul><ul><ul><li>Muscle spasms </li></ul></ul><ul><ul><li>Decreased ROM </li></ul></ul>
  34. 34. Cold Whirlpools <ul><li>Duration of Tx </li></ul><ul><ul><li>15-20 minutes </li></ul></ul><ul><ul><li>Temp 50° - 60 ° F </li></ul></ul><ul><li>Indications </li></ul><ul><ul><li>Decrased ROM </li></ul></ul><ul><ul><li>Cryokinetics </li></ul></ul><ul><ul><li>Subacute to chronic inflammation </li></ul></ul><ul><ul><li>Peripheral nerve injuries (avoid extremes) </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Acute conditions where water turbulence would further irritate area </li></ul></ul><ul><ul><li>Gravity </li></ul></ul><ul><ul><li>Postural </li></ul></ul><ul><ul><li>Skin Conditions </li></ul></ul><ul><ul><li>All other ice contraindications </li></ul></ul>
  35. 35. Cryotherapy take home points <ul><li>Immediate care needs 30+ min to prevent secondary injury (ch. 12) </li></ul><ul><li>Intermediate care needs 12-20 min to decrease pain & facilitate ther ex (ch. 12) </li></ul><ul><li>Cold-Induced Vasodilation is a myth (ch. 12) </li></ul><ul><li>Ice is safer to the skin & it extracts more heat than gel packs (ch. 5) </li></ul><ul><li>The longer cold is applied, the slower tissue rewarms (ch. 5) </li></ul><ul><li>Elastic wraps compress better than flexi-wrap (ch. 5) </li></ul>
  36. 36. Cold Case Study, Due 2/22 <ul><li>Submit electronically on blackboard is preferred, but paper OK at start of class </li></ul><ul><li>10 pts based on good use of sources, good thought process, clear explanation of concepts </li></ul><ul><li>As mentioned in assignment, site 3 primary (journal) sources; secondary (textbook) sources do not count </li></ul><ul><li>Form for citation: </li></ul><ul><ul><li>Author last names First initials. Study Title. Journal Title , year; volume: page numbers. </li></ul></ul>

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