Transcript Superficial Thermal Agents - Lectures

Thermotherapy
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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
Thermotherapy Effects
• Local Effects
 metabolic rate
Vasodilation
 capillary permeability
 nerve conduction
velocity
–  pain
–  muscle spasm
– Edema formation
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• Systemic Effects
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 body temperature
 pulse rate
 respiratory rate
 blood pressure
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
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
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
Rebound Vasoconstriction
• Approximately 20 min. into treatment (after
maximum vasodilation has occurred &
intensity of treatment stays constant) vessels
constrict
Indications
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Subacute & chronic phases
 ROM
 Lymphatic drainage
 Blood flow
 Cellular metabolic rate
 Body temperature
 Pulse rate
 Respiratory rate
 Pain
 Muscle spasm
Contraindications
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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)
• 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
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
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
Application of Thermotherapy
• Paraffin Bath - 125°-127°F
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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
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.
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
Superficial
Vs.
• 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
Deep Heat
• Heat penetrates into
tissue
– Ultrasound
– Depth of heating 5-6 CM
How long does the heating effect last?
• Hot Packs - @
depth of 1 CM,
45-60 minutes
Physiological effects of heat
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Vasodilatation
Vasoconstriction
Pain relief
Increase tissue
extensibility (before ROM)
• Increase blood flow
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
(Physiological effects of heat Cont. )
• 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.
Effects of Heat on Strength
• In 1st 30 minutes, strength decreases
• In next 1 1/2 hour, strength increases
• Endurance decreases when heated
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
So what?
• Ice may be more beneficial
than heat with
inflammatory
conditions
Skin Temperature Sensitivity
• 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
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?
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
Contrast Therapy
• Most effective treatment time hasn’t been
determined
• Commonly used 3:1 or 4:1 ratio to equal 20
mins.
– 4:1
C:H
3:2
C:H
2:3
C:H
1:4
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
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 !!!
Indications for Hot Packs
• Pain from muscle tears, ligament strains or
sprains
• Muscle or tendon tightness
• Joint stiffness
Thermotherapy (Heat)
– Hydrocollator
packs
• Treat 20 minutes
• 150-160 degrees
– Will burn!
Must pad with
layered towels
or covers!
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
Hot Packs Cont.
• Which size HP to use
• More pts burned
HP than
with
anything else
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
Paraffin Bath
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Frequently used with arthritis
Hand is immobile during treatment
Useful when motion is not indicated
Paraffin temp - 1300
Have pt wash hands
• Pt dips hand 6-10 times
• While dipping, keep fingers still
• Dip quickly, then lift until paraffin
stops dripping
• 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
• 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?
Types of pts who may benefit from
paraffin
• Arthritis
• simultaneous stretch & heat
– stiff PIPJ
• Conditions where motion is not indicated
• Schleroderma
Indications for fluidotherapy
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Joint stiffness
Muscle or tendon tightness
Spacticity
Pain in the hand
Indications for fluidotherapy
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Joint stiffness
Muscle or tendon tightness
Spacticity
Pain in the hand
Fluidotherapy
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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
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)
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
• A splint or device to stretch joint can be
applied during fluidotherapy
Fluidotherapy Controls
• Air speed 0100
• Pulse time
– P1=1 sec
on,1 sec off
– P2=2 sec on,
2 sec off
– P3, P4, P5,
P6
Food for Thought
• If you have a blood clot in one arm, can you
use a heat modality on the other arm?
Light Modalities
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
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
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
Types of Infrared Lamps
• Near-Infrared
– Luminous Infrared Lamp
– Wavelength: 780 to 1,500 nm (closest to visible
light)
– Thermal Effects: 5 to 10 mm deep
– Energy formed by carbon and tungsten filament
• Light bulb
• Some energy is reflected by the surface of the skin
Types of Infrared Lamps
• Far-Infrared
– Nonluminous Infrared Radiation
– Wavelength: 1,500 to 12,500 nm
– Thermal Effects: < 2mm
• Less penetrating than Near-Infrared
– Skin feels warmer
– Energy formed by metal coil
• i.e. electric stove or space heater
• Invisible to human eye
Effects of Infrared Lamps
• Constant, dry heat to assist with superficial
tissue
– Dermatological conditions
– Increase cell metabolism
– Blood flow
– Muscle Relaxation
• Contraindications
– Any conditions in which other forms of
superficial heat are contraindicated
Clinical Applications
• Turn On and warm if necessary
• Treatment Duration: 20 to 30 minutes
• Intensity: adjust wattage or distance of lamp
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Luminous = 24 inches
NonLuminous = 32 inches
Inverse Square Law
Cosine Law
• Clean sweat and dirt, remove jewelry, and fit infrared
goggles (if applicable) for patient
Ultraviolet Therapy
• Used to produce photochemical reactions in
the skin
• Wavelength: 180 to 400 nm
• 3 UV bands (A, B, and C) produce unique
effects
Types of UV
• UV-A
– AKA: near UV
– Effects: Erythema without pigmentation
• UV-B
– AKA: middle UV
– Effects: Erythema without pigmentation,
formation of vit D, skin tanning (blister/burn)
• UV-C
– AKA: far UV
– Kills bacteria, formation of vit D, skin tanning
Types of UV Lamps
• ‘Hot’ UV Lamps
– Low Volt (30-110V) High-Amp (5A)
– Electrical current passes through tube, argon
gas heats, vaporizing and polarizing mercury to
produce UV light in ALL 3 bands and visible
violet light
• ‘Cold’ UV Lamps
– High Volt (3000V) Low-Amp (15mA)
– Energy is cooler than ‘Hot’ and produce UV-C
Biophysical Effects
• Energy absorbed at a depth between 0.20 to 0.22
mm
• Damages cell proteins, DNA, & RNA to initiate local
inflammatory responses
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Vitamin D synthesis
Enhances melanin production
Thickens epidermis
Superficial vasodilatation
Bactericide
Effects of UV Lamps
• Wound Healing
– Activates inflammatory response
– Use: Cold Lamps at intensity of E3
• Treat Skin Disorders
– i.e. psoriasis
– Exfoliates tissue and damage DNA that produces the
excess skin growth associated with psoriasis
– Use: UV-B
UV Contraindications
• Sunlight sensitivity
• Fair skin (precaution)
• Medications or food that increase sunlight
sensitivity
• Hyperthyroidism
UV Dosage
• Determined by Minimal Erythema Dose
– Least amount of UV exposure time to produce
redness within 1-6 hrs and disappear within 24
hours
• ‘Hot’ Lamps
– Determined by each patient and each lamp
– Standard distance = 30 in., not closer than 15 in.
• ‘Cold’ Lamps
– Standard MED value
– 12-15 seconds at a distance = 1 in.
Determining MED for UV Lamp
• Cardboard Test Strips
1. 6 different shapes cut out
2. Use to cover shapes
• UV Lamp 30 in. away
• Exposes 1 cut out, open the shutters for 30- sec.,
expose the 2nd cut out and leave the 1st uncover
for the 30-sec.
• Repeat the steps above for the remaining 4 cut
outs, but expose them at 15-sec intervals
• Instruct patient to check area every hour and
record changes
UV Treatment Dosage
• SED
– No erythema
• MED
– Smallest dose that produces erythema within 1-6 hr
• E1
– Erythema lasts for 1-3 days, some scaling of skin present,
approximately 2.5x MED
• E2
– Erythema with edema, peeling, and pigmentation,
approximately 5x MED
• E3
– Severe erythema and burning, blistering, peeling, edema,
approximately, 10x MED
Clinical Application
• Calculate treatment dose and duration
• Clean area and remove jewelry
• Cover skin not being treated (sunscreen if
applicable)
• Fit UV-resistant goggles to patient and clinician
• Position lamp at right angle using the correct
distance and duration for each type of lamp
• Clean machine and check periodically for
maintenance of bulbs
Adjusting the Treatment Dose
• Biophysical changes occur with light exposure
causing changes in treatment
• Duration
– 30 to 50% increase for each subsequent treatment
– If 3 to 5 minutes, then distance is reduced
– 5 to 10 sec is decreased when missing a treatment
• Be aware of patients skin color and the lamps
distance, duration, and angle
Therapeutic Lasers
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L=Light
A=Amplification by
S=Stimulated
E=Emission of
R=Radiation
Classified by the FDA’s Center for Devices and
Radiological Health
Production of Laser Energy
• Lasers are referred to by the type of active
medium (gas, liquid, solid)
– HeNe: visible red light penetrating 0.8 to 15mm
– GaAs: invisible penetrating up to 2 cm
• Energy is introduced into the active medium
• An orbiting electron briefly elevates into a higher
or ‘excited’ state
• The electron spontaneously returns and releases
another photon
Effects of Lasers
• Photons are absorbed by tissues to alter
molecular-level activity
• Theorized to affect pain-producing tissue
(muscle spasm), by increasing ATP synthesis
that increases cell metabolism and encourages
the release of free radicals
Wound Healing
• Superficial wounds
– Ulcers, surgical insicison, burns
• Lasers alter cell membrane permeability and
increase in fibroblast, lymphocyte, and
macrophage activity occurs
• Blood and lymph improve to promote the
growth of granulation tissue
• Increase collagen and tensile strength of
healing wounds
Pain Reduction
• Decrease acute and chronic pain
• Reduce the rate and velocity of sensory nerve
impulses
– Similar to cryotherapy but without thermal
changes
Fracture Healing
• May enhance fracture healing and bone
remodeling by increasing capillary formation,
calcium deposition, increase callus formation,
and reducing hematomas
• Photons striking the tissue create acoustic
waves that affect bone healing similar to
ultrasonic bone growth stimulators
Clinical Application
• Because of the investigational status of
therapeutic lasers, the clinical application is
not described.
Hydrotherapy
Physical Principles
• Achieves affects through:
• Forces Existing in Water
– Buoyancy
• Archimedes Principle of Buoyancy
– Pressure
– Cohesion
– Viscosity
Methods of Heat Transfer
• Conduction
• Convection
• Radiation
Biophysical Effects
• Thermal Effects
– Local and systemic effects
• Mechanical Effects
– Agitation
• Analgesic effects
• Counterirritant
• Altering agitation
General Description and Unit
Operation
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Types of WP
Hydrotherapy Area
Turbine
Whirlpool Care and Safety
– Cleaning
– Blood-borne pathogens
– Electrical Safety
Clinical Indications for
Hydrotherapy
• Wound Care
– How
– Whirlpool additives
• Exercise Assistance
– General Aim
– Principle of Exercise in Water
– Peripheral Nerves
Hydrotherapy
Contraindication/Precautions
• Contraindications
– Acute Conditions
• Gravity dependent position and agitation
– Fever
• Precautions
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Ground fault interrupter
Patient should not turn on/off
Don’t leave athlete alone
Gravity dependent position
Do not run turbine dry
Do not run turbine with ice still melting
Watch for signs of fainting
General Guidelines for Clinical
Administration of Hydrotherapy
• Preparatory Considerations
– ID treatment objectives
– Tx temp
– Evaluate Athlete
– Tx Duration
Warm Whirlpool
• Rationale for Use
• Treatment
– Agitation = 6-8 inches from segment
– Temperature
• Arm and hand = 98-110
• Lower extremity = 98-104
• Full body = 98-102
– Tx time
• Physiological Considerations
• Considerations