Thermotherapy

By Ren Peterson, Laurel Petersen, Jason Neilsen,

Angela Perkins

Objectives

11

Educate on the physiologic effects of different thermotherapy agents. Inform on the indications, contraindications, precautions, and recommendations for a variety of thermotherapy agents. Identify and demonstrate how various thermotherapy agents are applied to biological tissues. Have fun while learning.

Instructions

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Main Menu

History Perspective General Information on Thermotherapy Moist Heat Packs

Paraffin Baths
Fluidotherapy Infrared Lamp Warm whirlpool/Immersion

Historical Perspective of Thermotherapy 8

Heat has always been used in various form for therapeutic benefits. The first sources of heat that provided an effective treatment for ailments and pain included sunlight, heated sand, and heated water. Early users of thermotherapy also obtained heat form hot stones and coals, open fire, and irons. The earliest hot water containers consisted of hollow dried fruits and bladder or skin of animals. The first scientific inquiries into the use of thermotherapy were conducted in the early 19th century.

Considerations

Pre treatment considerations

Adipose tissue thickness Stage of healing Contraindications

During treatment Considerations

Patient comfort/Safety Treatment efficacy

Post Treatment Considerations

Moist Heat Packs 10

Biophysical Characteristics Application Recommendations Evidence-Based Research

Biophysical Characteristics 1
Moist Heat Packs

Increased blood flow/vasodilatation. Increased cell metabolism. Muscular relaxation secondary to reducing muscle spindle sensitivity.

Application
Moist Heat Packs

10

Indications Contraindications Dangers/Precautions Demonstration of set-up Proper Application

Indications 1
Moist Heat Packs

Subacute or chronic inflammatory conditions Reduction of subacute or chronic pain Subacute or chronic muscle spasm Decreased ROM Hematoma resolution Reduction of joint contractures Infection

Contraindications 1
Moist Heat Packs

Acute conditions- because of increase of inflammation Peripheral vascular disease (PVD) Impaired circulation Poor thermal regulation

Dangers/Precautions 1
Moist Heat Packs

Do not allow the moist heat pack to come into direct contact with the skin because burns may result. If the packs are changed during the course of the treatment, additional care must be taken to prevent buns. Infected areas must be covered with sterile gauze or another type of material to collect seepage. Do not allow the patient to lay on the pack. If you must, increase space between by adding extra layers.

Demonstration of set-up
Moist Heat Packs

Proper Application 1,9

Moist Heat Packs

Moist heat packs should be stored in hydrocollator at 160F to 170F. Use 6 layers of toweling or insulation to protect patient. Recheck patient after 5 minutes for comfort and mottling. Treatment time should be between 20 to 30 minutes. Treatments may be repeated as needed, but allow skin to cool before next treatment is given

Recommendations 1
Moist Heat Packs

Localized superficial heating Pain Muscle spasm Chronic inflammatory conditions Increasing muscle, tendon, and fascial elasticity.

Evidence-Based Research
Moist Heat Packs

2,12

STUDY 1: 30 healthy subjects compared the efficacy of a 30

second static stretch to a 20 minutes moist heat pack application on hamstring flexibility. The study found that applying a moist heat pack increased hamstring flexibility significantly more than using a static stretch (p<0.03). STUDY 2: 30 subjects (9 men and 21 women) with frozen shoulder used a single-blinded randomized controlled study comparing shortwave diathermy & stretching, hot pack & stretching, and stretching alone one pain, function, and ROM. The study found that There was not a significant difference found in pain or function between groups, all improved. However, shortwave diathermy and hot pack administration both improved ROM, with diathermy showing greatest improvement (p<0.05)

Paraffin Baths

Biophysical Characteristics Application Recommendations Evidence-Based Research

Biophysical Characteristics 1
Paraffin Baths

Increases perspiration Increases blood flow/vasodilation Increased cell metabolism

Applications
Paraffin Baths

Indications Contraindications Dangers/Precautions Demonstration of set-up Proper Application

Indications 1
Paraffin Baths

Subacute and chronic inflammatory conditions Limitation of motion after immobilization

Contraindications 1
Paraffin Baths

Open wounds: Wax and oil would irritate the tissues. Skin infections: The warm, dark environment is excellent for breeding bacteria Sensory loss Peripheral vascular disease

Dangers/Precautions 1
Paraffin Baths

General Population

Do not allow the patient to touch the bottom or sides of the paraffin tank as burns may result.
The sensation of the paraffin is misleading as to the actual temperature of the treatment. The temperature of the paraffin is sufficient to cause burns, but its specific heat requires more time to transfer the energy

Elderly

Dangers/Precautions1
Paraffin Baths

Athletes

Avoid using paraffin with athletes who are required to catch or throw a ball or workers who are required to maintain good grip after the treatment. The mineral oil in the paraffin mixture tends to make the hands slippery, making the task of catching a ball or holding onto a hammer difficult.

Demonstration of Set-up
Paraffin Baths

Proper Application
Paraffin Baths

1,9

Glove Method The extremity should be dipped into the paraffin for a couple of seconds, then remove to allow wax to harden. Repeat process 7 to 12 times. The paraffin-coated extremity should be wrapped in a plastic bag with several layers of toweling around it to act as insulation. Treatment time is 15 to 20 minutes. Treatment may be repeated several times a day.

Recommendations 1
Paraffin Baths

Paraffin is used for delivering superficial heat to small, irregularly shaped areas. The treatment of chronic inflammatory conditions Softening of the skin

Evidence-Based Research 4
Paraffin Baths

A study of 17 patients with Sclerosis compared two treatment methods. One group received a paraffin bath treatment followed by hand exercises. The other group only performed hand exercises. Improvements in function were significantly greater in the hand which was treated with paraffin bath exercise than in hand treated with exercise only. Improvements were increased finger flexion and extension, thumb abduction, volar flexion in the wrist, and perceived stiffness and skin elasticity.

Fluidotherapy

Biophysical Characteristics Application Recommendations Evidence-Based Research

Biophysical Characteristics1
Fluidotherapy

Increased blood flow/vasodilation Increased cell metabolism Muscular relaxation secondary to reducing muscle spindle sensitivity.

Application
FLuidotherapy

Indications Contraindications Dangers/Precautions Proper Application

Indications 1
Fluidotherapy

Pain reduction Aid in joint mobilization ROM exercises while doing treatment Non-rheumatoid arthritis

Contraindictions 1
Fluidotherapy

Uncovered open wounds Sensory Loss Peripheral vascular disease Over cancerous lesions Decreased tolerance to heat.

Dangers/Precautions 1
Fluidotherapy

Cover open wounds prior to treatment. Be aware that some patients are sensitive to allergic reactions caused by dust or pollen.

Proper Application1 Fluidotherapy

Ensure that the patient is free of contraindications. Preheat the fluidotherapy unit. Remove jewlery from body part being treated. Wash and dry patients extremity using an antimicrobial soap. Prevent medium from entering open wounds by a nonpermiable covering.

Recommendations1
Fluidotherapy

Superficial heating of the skin of the upper or lower extremities. Decreases pain. Increase ROM.

Evidence-Based Research10
Fluidotherapy

In a study by Borrell it was found that fluidotherapy produced a greater increase of joint capsule and intramuscular temperatures than that of hydrotherapy and paraffin wax. Joint capsule and intramuscular temperatures were as follows: fluidotherapy +16.2, +9.5; paraffin wax +13.5, + 8.1; and hydrotherapy +10.8, 7.7 degrees Fahrenheit respectively.

Infrared Lamp

Biophysical Characteristics Application Recommendations

Biophysical Characteristics 1
Infrared Lamp

Increased blood flow/vasodilation Increased cell metabolism Muscular relaxation secondary to reducing muscle spindle sensitivity.

Application
Infrared Lamp

Indications Contraindications Dangers/Precautions Proper Application

Indications1
Infrared Lamp

Subacute or chronic inflammatory conditions. Skin infections. Peripheral nerve injuries before electrical stimulation: Another modality should be considered if the patient lacks temperature perception.

Contradications 1
Infrared Lamp

Acute inflammatory conditions. Peripheral vascular disease. Areas with sensory loss. Over areas of scars. Sunburns.

Dangers/Precautions 1
Infrared Lamp

The infrared heating element does not cool during the treatment, thus providing a constant level of energy. The unchanging temperature source increases the risk of burns. Check with the patient regularly. Do not use on a sleeping or unconscious patient.

Proper Application 1
Infrared Lamp

Check for any contraindications. Clean area to be treated. Position patient so that the lamp is perpendicular to the targeted tissue. Position the lamp 24 inches from target tissue. Instruct patient to not move. Check the patient often. Instruct the patient to tell the clinician of any burning sensation.

Recommendations 1
Infrared Lamps

Often used as a superficial heating agent. Drying superficial tissues. Sedating sensory nerves.

Warm whirlpool/Immersion

Biophysical Characteristics Application Recommendations Evidence-Based Research

Biophysical Characteristics 1
Warm whirlpool/immersion

Provides a good supportive medium for active ROM exercises

Due to the physical characteristics of water, buoyancy, resistance, and hydrostatic pressure.

Promotes muscular relaxation Decreases pain & muscle spasms

Due to the agitation & aeration of the water causing sedation, analgesia, and increased blood flow.

Application
Warm whirlpool/immersion

Indications Contraindications Dangers/Precautions Demonstration of set-up Proper Application

Indications 1
Warm Whirlpool/Immersion

Decreased ROM Subacute or chornic inflammatory conditions Peripheral vascular disease (neutral temp) Peripheral nerve injuries

Contraindications 1
Warm Whirlpool/Immersion

Acute conditions in which water turbulence would further irritate the injured area or in which the limb is placed in a gravitydependent position. Fever Patients requiring postural support during treatment Certain skin conditions speared by water General contraindications for thermotherapy

Dangers/Precautions 1
Warm Whirlpool/Immersion

Heat loss can only take place in two forms: evaporation & respiration. Therefore, a patients core temperature can be increased too much and cause hyperthermia. The pressure associated with full-body immersion may impair breathing in individuals suffering from advance respiratory disease

More Dangers/Precautions 1
Warm Whirlpool/Immersion

Temperature must be decreased as the total body area immersed increases Moderate to strenuous workouts while immersed will further increase body core temperature Must be connected to a ground-fault circuit interrupter Instruct patient not to turn the motor on or off while in the water

More Dangers/Precautions 1
Warm Whirlpool/Immersion

Patients must be supervised by a staff member at all times The flowing water may nauseate some patients, especially those prone to motion sickness. Patients under the influence of drugs, alcohol, or those who have seizure disorders or heart disease are at risk of losing consciousness during treatment.

Demonstration of Set-Up
Warm Whirlpool/Immersion

Proper Application
Warm Whirlpool/Immersion

Water temperature of 90F to 110F Initial treatments are given for 5-10 mins

The duration of treatments may increase to 20-30 mins as patient processes in their individual program.

When treating deep structures, duration of treatment should increase as the amount of adipose tissue increases Treatments may be given once or twice a day

Recommendations 1
Warm Whirlpool/Immersion

Large irregular shaped areas Possible to do ROM activities/exercise while receiving thermal treatment

Evidence-Based Research
Warm Whirlpool/Immersion

A study using 56 subjects was conducted to compared the efficacy of warm whirlpool, cold whirlpool, and constrast therapy in the treatment of delayed-onset muscle soreness. The study found that contrast therapy & was found to decrease perceived soreness significantly more than warm whirlpool or no treatment. (P<.01). In addition, warm whirlpool was more effective than no treatment.

More Evidence-Based Research

Warm Whirlpool/Immersion

A study using 21 subjects was conducted to determine if cold whirlpool treatment decreases the functional performance equally regardless of gender. The tests used to determined functional performance were: counter movement vertical jump, T-test, 40-yard dash, and active range of motion of the ankle. Participants were treated with a 20 minute, 10 degree Celsius cold whirlpool following the pre-test of a given functional performance measure. The study found that the participants demonstrated significant decreases in counter movement vertical jump, T-test, and 40-yard dash performance immediately following treatment. Vertical jump performance remained impaired for at least 32 minutes. While both the T-test and 40-yard dash were affected for 7 and 22 minutes post- treatment, respectively. Participants also demonstrated significant decreases in peak power and average power immediately after and for 32 minutes post-treatment. Dorsiflexion was significantly decreased 7 and 12 minutes following treatment This suggest functional performance was affected immediately following and for up to 32 minutes after cold whirlpool treatment. It was also evident that there is a gradual performance increase for each measure of functional performance across time. Therefore, the consequences should be carefully considered before returning athletes to activity following cold whirlpool treatment.

Review Challenge
Select a button for a review quesion

Moist heat pack are stored in water at what temperature?

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160-170 F

How many layers should be in between the patients skin and the most heat pack?

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6 Layers

A paraffin bath contains a mixture of wax and mineral oil. What is the ratio between the two?

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Seven parts wax to one part oil (7:1)

Melted paraffin is kept at a constant temperature that ranges from ____ to ____ for upper extremity treatments.
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118F to 126F

How long should a moist heat treatment last?

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20-30 minutes

T/F You should allow the moist heat pack to directly contact the skin for adequate treatment?

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False

How far should an infrared lamp be positioned above the target tissue?

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24 inches

What is the danger of using infrared lamps?

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The modality does not cool down over time and therefore poses a greater risk for burning.

T/F It is recommended to proceed to treat a patient with thermal modalities if they have impaired circulation.

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False

Which thermotherapy treatment provides a good supportive medium for active ROM exercises?
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Warm whirlpool

T/F Temperature of a warm whirlpool must increase has the total body area immersed increases?

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False

The initial warm whirlpool treatment should be how long in duration?

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5-10 minutes

Warm whirlpools are best to treat what type of area?

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Large irregular shaped areas

A whirlpool must be connected to what to ensure patients safety?

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ground-fault circuit interrupter

What is an important Precaution with fluidtherapy?

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some patients are sensitive to allergic reactions caused by dust or pollen.

What type of Thermotherapy is used to treat Skin Infections?

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Infrared Lamp

T/f Borrell found that fluidotherapy produced a greater increas in joint capsule & Intramuscular temperatures than that of hydrotherapy
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True

How long should paraffin treatment times last?

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15-20 min

Because of paraffin baths low specific heat, it can provide approximately __ times the amount of heat as water

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Temperatures for whirlpool treatments given to the lower extremity are decreased to ____ to ___ .
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113F to 121F

References

1. Starkey, C. (2004). Therapeutic Modalities (3rd ed.). Philadelphia: F.A. Davis Company 2. Funk D, Swank AM, Adams KJ, Treolo D. Efficacy of moist heat pack application over static stretching on hamstring flexibility. Journal of Strength and Conditioning Research. 2001;15(1):123-126.

3. Kuligowski, L.A, Lephart, S.M., Giannantonio, F. P., & Blanc R. O. (1998). The Effects of whirlpool therapy on the signs and symptoms of delayed-onset muscle soreness. Journal of Athletic Training 33(3):222-228.
4. Gunnel, S., Anita, A., & Eklund, M. (2004). Evaluation of paraffin bath treatment in patients with systemic sclerosis. Disability & Rehabilitation. 26 (16): 981-987. 5. Sherry, E., & Wilson, S. F. (1998) Oxford handbook of sports medicine. New York: Oxford University Press Inc. 6. Prentice, W.E. (1999). Rehabilitaion Techniques in Sports Medicine (3rd ed.). Boston: WCB/McGraw-Hill Companies. 7. Fu, F. H., & Stone, D. A. ( 2001). Sports injuries: Mechanisms, prevention, and treatment (2nd ed.). Philadelphia: Lippincott Williams and Wilkins 8. Snyder, M., & Lindquist, R. (1998). Complementary Alternative Thearpies in Nursing (3rd ed.). New York: Springer Publishing Company. 9. Patterson, S. M., Udermann, B. E., Doberstein S. T., and Reineke, D. M. (2008). The effects of cold whirlpool on power, speed, agility, and range of motion. Journal of Sports Science and Medicine. 7: 387-394. 10. Borrell, RM., Parker, R., Henley, EJ., Masley, D., Repinecz, M., Comparison of in vivo temperatures produced by hydrotherapy, paraffin wax treatment, and fluidotherapy. Physical Therapy (1980); 60: 1273-6

11. Berry D. (2008). Power point presentation for Chapthers 5 & 6. Therapeutic Modalities. Ogden: HPHP copier.
12. Leung M.S., & Cheing G.L. (2008). Effects of deep and superficial heating in the management of frozen shoulder. Journal of Reabilitative Medicine. 40: 145-150.

General Indications

1,5

More commonly used for chronic inflammation and muscle spasm. Subacute inflammation Analgesic Effect Decreased ROM Hematoma resolution Reduction of joint contractures Psychologically, heat can be better tolerated than cold

General Contraindications

1,7

Early stages of acute injuries Impaired circulation Advanced arthritis (vigorous heating) Poor thermal regulation Anesthetic areas Neoplasms Thrombophelbitis Neurovascular deficits Elevated core temperature due to infection Malignant Tumors

Thermotherapy Affects

1,5,6,7

Smooth muscle of blood vessels

Vasodilation

Increases blood supply/flow

Increase volume of injured limb

Increase Cellular metabolism

Subsequent resolution of inflammation infiltration, edema, and exudate. Increases the delivery of oxygen & nutrients
Decrease ischemia

Blood and synovial fluid viscosity

Decreased viscosity as temperature increases

Thermotherapy affects cont

Peripheral nerve activity

Increases firing threshold of peripheral nerves producing an analgesia proximal to the application Causes a counterirritation, closing the gate to small pain fibers

Muscle spindle response

Skin stimulation by superficial heat may decrease gamma motor neuron activity and muscle spindle response with a subsequent reduction in striated muscle spasms.

Same effect of cryotherapy, but thermotherapy has a greater

effect

Extensibility of collagen

There is an increase in the tissues elasticity and plasticity due to the altered structure When combined with stretching or exercise leads to increased ROM