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  • 1. PTA 200Modalities and Procedures in Physical Therapy
    Superficial Heat and Cold
  • 2. Superficial Heat and Cold
    Primarily increase or decrease temperature of skin, superficial subcutaneous tissues
  • 3. Therapeutic Application
    Heating Agents
    Transfer heat to patient’s body, between various tissue/fluids
    Cooling Agents
    Transfer heat away from patient’s body
  • 4. Therapeutic Application
  • 5. Therapeutic Uses of Cold
    Control inflammation
    Decrease pain
    Decrease edema
    Decrease spasticity
    Facilitate movement
  • 6. Therapeutic Effects of Cold
  • 7. Hemodynamic Effects
  • 8. Hemodynamic Effects
    Immediate vasoconstriction
    Less than 15 minutes
    Stimulates smooth muscles of vessels to contract
    Decreases release of histamine, prostaglandins (vasodilators)
    Increases blood viscosity (increases resistance to flow)
    Decreases blood flow to maintain core temperature
  • 9. Hemodynamic Effects
    After 15 minutes, vasodilation occurs
    Mostly distal extremities
    Temperatures < 10 C (350 F) >15 minutes
    Cold induced vasodilation (COVD)
    Amount of vasodilation usually small
    Skin redness NOT due to vasodilation
    Due to increase in oxyhemoglobin concentration of blood
    Cold decreases oxyhemoglobin dissociation
    Makes less oxygen available to tissues
    Hunting Response
    Response to pain associated with extreme cold
  • 10. Neuromuscular Effects
  • 11. Decreased Nerve Conduction Velocity
    Proportional to degree and duration of temperature change
    Application of cold > 5 minutes
    Reverses (normal) within 15 minutes
    After 20 minutes, may take 30 minutes or more to recover.
  • 12. Decreased Nerve Conduction Velocity
    Decreased NCV of sensory and motor nerves occurs
    Greatest effect in myelinated, small fibers
    pain transmitters
    Least effect in unmyelinated, large fibers
  • 13. Increased Pain Threshold
    Counter-irritation via Gate Theory
    Secondary to decrease in muscle spasm
    Secondary to decrease in sensory NCV
    Secondary to post-injury edema reduction (decreased blood flow)
    Reduces pressure on nerves due to edema
  • 14. Decreases Spasticity
    Decrease in gamma motor neuron activity (stretch reflex)
    After 10-30 minutes, decrease in afferent spindle, GTO activity.
    Caused by decrease in muscle temperature
    Can last for 1- 1.5 hours
    Application of cold up to 30 minutes in patient with increased tone,
    will decrease tone for up to 1-1.5 hours
  • 15. Facilitation of Muscle Contraction
    Brief application (few seconds) facilitates alpha motor neuron activity
    Produces muscle contraction in flaccid muscle.
    CVA, SCI
    Prolonged cold (few minutes) decreases force of contraction
  • 16. Metabolic Effects
  • 17. Decreases Metabolic Rate
    For inflammation
    For healing
    not recommended for patient with delayed healing
    Cartilage-degrading enzymes decreased
    OA, RA
  • 18. Inflammation Control
    Decreases chemical reactions secondary to acute inflammatory response
    Decreased blood flow secondary to vasoconstriction, increased viscosity
    Causes secondary decrease in bleeding, edema
    (normally) Increased function during this stage of healing
  • 19. Inflammation Control
    If temperature of tissue remains elevated…
    Cryotherapy remains indicated (48-72 hrs)
    After activity there is secondary acute inflammatory response
    may need to continue cold for some time
  • 20. Inflammation Control
    Prophylactically after exercise to decrease DOMS
    Delayed Onset Muscle Soreness
    Due to muscle connective tissue damage secondary to exercise
  • 21. Inflammation Control
    Duration of treatment typically 15 minutes , except spasticity control
    In general, applications 1 hour apart
    Tissue temperature can return to normal
  • 22. Edema Control
    Decreases intravascular fluid pressure via decreasing blood flow, increased viscosity
    Most effective if applied immediately, in conjunction with elevation and compression
  • 23. R-I-C-E
    R: Rest
    I: Ice
    C: Compression
    E: Elevation
  • 24. Edema Control
    Cryotherapy ineffective with edema secondary to immobility and poor circulation.
  • 25. Pain Control
    10-15 minute application can control pain for 1 or more hours.
    Rarely used. (Rood)
  • 26. Cryokinetics
    To apply cooling agent to point of numbness shortly after injury,
    to decrease sensation of pain, allow patient to exercise toward regaining ROM ASAP. (Athletics)
    Cold for 20 minutes (numbness)
    Exercise for 3-5 minutes
    Repeat about 5 times
  • 27. Cryostretch
    Cooling prior to stretching
    Decreases spasm, secondary increase in ROM
    Spray n’ Stretch,
    Fluoro-methane Spray
    If patient condition not improving or worsening within 2-3 treatments,
    Approach should be re-evaluated and changed, or
    Refer to MD
  • 28. Contraindications
  • 29. Contraindications for Cold
    Coldhypersensitivity or intolerance
    Uncommon disorder
    Aggregation of serum proteins in distal circulation when distal extremities cooled
    Proteins form a “gel” that can impair circulation,
    Causes local ischemia, gangrene
    Paroxysmal Cold Hemoglobinuria
    Release of hemoglobin into urine from lysed red blood cells,
    In response to local or general exposure to cold
  • 30. Contraindications for Cold
    Raynaud’s Disease
    Paroxysmal digital cyanosis
    Sudden pallor followed by redness of skin of digits,
    Precipitated by cold or emotional upset
    Relieved by warmth
    Bilateral and symmetric (women)
    Raynaud’s Phenomenon
    Generally only in one extremity
    May be associated with thoracic outlet, carpal tunnel syndrome or trauma
  • 31. Contraindications for Cold
    Regenerating Nerves
    Local vasoconstriction or decreased nerve conduction may delay regeneration
    Circulatory compromise or peripheral vascular disease
    Chronic peripheral vascular disease may have edema
    Cold may increase this edema
    Indicators for swelling due to Peripheral vascular disease
    Pallor and coolness
  • 32. Precautions
  • 33. Precautions
    Over superficial main branch of a nerve
    Over an open wound
    delays healing
    can cause transient increases in systolic or diastolic BP
    Patients with poor sensation or mentation
    Very young or very old
    impaired temperature regulation,
    ability to communicate
  • 34. Adverse Effects
  • 35. Adverse Effects
    Tissue Death
    Frost Bite
    Nerve damage
    Unwanted vasodilation due to prolonged vasoconstriction, ischemia, thromboses in smaller vessels.
    Freezing of tissues
    damage at 39 degrees F
    To avoid, duration limited to under 45 minutes and tissue temperature above 39 degrees F
    When goal is vasoconstriction, treatment limited to 10-15 minutes
  • 36. Application, General Rules
  • 37. Application of Cold
    Assess patient and establish goals of treatment
    Determine if cryotherapy most appropriate treatment
    No Contraindications
    Select appropriate mode of application based on body part and desired response
    Explain procedure, reasons for treatment, and expected sensations
  • 38. Sensory Response to Cryotherapy
    Due to stimulation of thermal receptors and pain receptors
    followed by blocking of nerve conduction
    In this order:
    Intense cold
    Analgesia, numbness
  • 39. Cold Packs and Ice Bags
  • 40. Cold Packs/ Ice Packs
    Silica or mix of saline/gel
    Stored in freezer at 23 C
    Moldable to patient’s body
    Should be cooled at least 30 minutes between treatments or 2 hrs. prior to initial use.
  • 41. Application of Cold
    Ice Bags
    Crushed ice best
    conforms better
    Get all/most air out of bag.
    Colder than ice packs
    specific heat of ice higher than gels
    Either decrease time or provide slight insulation.
  • 42. Application of Cold Packs
    Home Treatment
    Ice bags, or frozen peas/vegetables
    Remove frost from outside of bag or insulate with towel.
    Homemade cold packs
    4:1 mix of water, rubbing alcohol
  • 43. Application of Cold Pack/ Ice Bags
    Use warm damp towel with cold pack, dry towel with ice bag (?)
    Secure pack with strap or ace wrap
    Elevate extremity if indicated
    Position patient comfortably
    Check skin periodically
    Give bell/ set timer
  • 44. Advantages and Disadvantages
  • 45. Advantages of Ice Packs/Cold Packs
    Easy to use
    Short use of clinician’s time
    Low skill level required
    Covers moderate to large areas
    Can elevate limb simultaneously
  • 46. Disadvantages
    Must remove pack to inspect skin
    Patient may not tolerate weight
    Difficult to mold to contoured areas
    Longer treatment time (than ice cup)
  • 47. Ice Massage or Ice Cup
  • 48. Ice Massage
    Ice cups or frozen water “Popsicles”
    Styrofoam nice, but often bust as ice expands
  • 49. Application of Ice Massage
    Use towels in surrounding areas to catch drips.
    Use small, overlapping circles
    Keep ice moving rapidly
    Continue for 5-10 minutes or until analgesia achieved
    “Quick Icing” used as quick strokes with ice cup to facilitate motor response
  • 50. Advantages of Ice Massage
    Treatment area can be observed during treatment
    Excellent for small, irregular areas
    Short-duration of treatment
    Increases compliance
    Can elevate limb if desired
  • 51. Disadvantages of Ice Massage
    Requires clinician throughout treatment, unless patient independent
  • 52. Intermittent Cold Compression and Cryocuff
  • 53. Controlled Cold Compression
    Intermittent Compression/ Cold Pump
    Usually used in post-op patients
    Allows for intermittent cold and compression
    proven more effective than ice alone
  • 54. Cryocuff
    Relatively inexpensive
    Effective compression with cold
    Patients often need assistance in applying device
  • 55. Vapocoolant Sprays
    Ethyl chloride
    Fluorimethane sprays
    Work by rapid cooling
    Desired treatment of trigger points
    Applied in parallel strokes along skin of muscle immediately prior to stretching
  • 56. Vapocoolant Sprays
    Often done after injection
    Purpose is to provide counter-stimulus
    Causes reflex decrease in motor neuron activity
    Secondary decrease in resistance to stretch
  • 57. Documentation of Cryotherapy
    Area of body treated
    Type of cryotherapy used
    Treatment duration
    Patient position
    Response to treatment