T ModalChapter4

Chapter 4: Thermotherapy and
Cryotherapy
Infrared Modalities
• Most of the heat and cold modalities have
wavelengths and frequencies that fall in the infrared
portion of the electromagnetic spectrum
 Ice Massage
 Cryo-cuff
 Commercial cold packs
 Ice packs
 Cryokinetics
 Cold whirlpool
 Warm whirlpool
 Cold spray
 Hydrocollator packs
 Contrast Baths  Paraffin baths
 Ice immersion  Infrared lamps
 Fluidotherapy
© 2009 McGraw-Hill Higher Education. All rights reserved.
• While these modalities are considered infrared
modalities they may be better described as
conductive thermal energy modalities
• Typically used to produce a local and/or

generalized heating/cooling effect
– Cryotherapy
– Thermotherapy

Mechanisms of Heat Transfer
• Transmission of heat occurs by three

mechanisms:
n Conduction
n Convection
n Radiation
*Conversion (involves change in one energy form to another)

Appropriate Use of
Infrared Modalities
• Thermotherapy
– Heating techniques used for therapeutic purposes
– Used when a rise in tissue temperature is the goal
of treatment
• Cryotherapy
– Used in the acute stages of the healing process
immediately following injury when a loss of
tissue temperature is the goal of therapy

Appropriate Use of
Infrared Modalities
• Cold application is often continued

throughout the rehabilitation and re-
conditioning process of an injury
• Hydrotherapy is also included (hot or cold)

as water can be used as the medium through
which heat is transferred

Appropriate Use of
Infrared Modalities
• Knowledge of the injury mechanism,

pathology and healing process are critical
when determining appropriate hot and cold
application
• Simple, efficient, and inexpensive means of

patient care

Clinical Use of Conductive
Energy Modalities
• Physiologic effects are rarely the result of

direct absorption of infrared energy
• No form of infrared energy can have a
depth of penetration greater than 1 cm
• Effects of infrared modalities are primarily
superficial and directly affect cutaneous
blood vessels and nerve receptors

• If significant amounts of energy are absorbed
over time, temperature of circulating blood will
increase
– Hypothalamus reflexively increase blood flow to
the area
– The reverse is true with cold application
– Deep heating modalities (US, diathermy) may be
more beneficial when increased blood flow to
deeper tissues is desired

• Most effective use of infrared modalities should be
to provide analgesia or reduce sensation of pain
associated with injury
– Gate control theory of pain modulation
• Pain reduction to facilitate therapeutic exercise is
common practice
• Continued research and investigation is necessary
to provide athletic trainers with effective and
efficient means of injury treatment

Effects of Tissue Temperature
Change on Circulation
• Main physiologic effect is on superficial
circulation
– Changes due to response of temperature receptors
in skin and sympathetic nervous system
• When cold is applied the skin vessels
progressively constrict to a temperature of
about 15° C (59° F) at which point they reach
maximum constriction

Change on Circulation
• At temperatures below 15° C vessels begin to
dilate
– Caused by paralysis of contractile mechanism in
vessel wall or blockage of nerve impulses
• General exposure to cold causes sympathetic
nerves to elicit cutaneous vasoconstriction,
shivering, piloerection, and an increase in
epinephrine secretion so vascular contraction
occurs
• Simultaneously, metabolism and heat production
increase
– Aids in increasing core temperature
• Increased blood flow will also result in increasing

oxygen to the area
– Results in analgesic and relaxation effects on muscle
spasm
– Increased proprioceptive reflex may explain these effects

• Three types of sensory receptors in sub-epithelial
tissue
– Cold, warm, pain
– Each responds differently at different temperatures
– Adapt to changes in temperature, with rapid
temperature change = more rapid adaptation
• Stimulation of larger surface areas results in
summation of thermal signals  trigger
vasomotor centers in hypothalamus

Change on Muscle Spasm
• Physiologic mechanisms underlying the
effectiveness of heat and cold treatments in
reducing muscle spasm lie at level of muscle
spindle and Golgi tendon organs
• Heat relaxes muscles simultaneously lessening
stimulus threshold of muscle spindles and by
decreasing gamma efferent firing rate
– Thus muscle spindles are more easily excited

• Muscles may be electromyographically silent
while at rest during application of heat, but
the slightest amount of voluntary or passive
movement may cause the efferents to fire
• Local applications of cold decrease local

neural activity

• Cold raises the threshold stimulus of muscle spindles,
and heat tends to lower it
• Local cooling results in a significant reduction of
muscle spasm greater than with use of heat
• Unclear if reduction of spasticity is caused by
excitability of motor neurons or hyperactivity of
gamma systems
• Cold effective in modifying stretch-reflex mechanism

• Nerve conduction velocity reduction also
occurs with cold application
– Decreases afferent discharge from cutaneous
receptors

Change on Performance
• Cryotherapy
– Some disagreement on relative concentric and eccentric torque
capabilities
– May not increase torque but may improve endurance
– Decreases vertical jump
– No impact joint range of motion
– Negatively impacts functional performance, which can be negated
via an active warm-up
– Minimal or no effect on joint position sense, proprioception,
balance and agility

Change on Performance
• Thermotherapy
– Minimal or no effect on joint position sense,
proprioception, and balance

Cryotherapy:
Physiologic Effects of Tissue Cooling
• General agreement that cold should be initial
treatment for musculoskeletal injuries
– Primary reason is to lower temperature in injured
area  reduces metabolic rate with a corresponding
decrease in production of metabolites and metabolic
heat (secondary hypoxic response)
• More effective when combined with compression
– Promotes vasoconstriction and helps to control
hemorrhaging and edema

Cryotherapy:
• Used immediately after injury to decrease
pain and muscle spasm
– Result of decreased nerve conduction velocity
– Cold stimulus bombards sensory receptors
resulting in pain modulation through gate control
• Effective in treating myofascial pain
• Effective in treating acute muscle pain as
opposed to delayed onset muscle soreness

Cryotherapy:
• Reduction in muscle guarding has been observed
clinically
• Initial reaction of body to cold is local vasoconstriction
– Results in decreased nutrient and phagocyte delivery to area
• Hunting Response
– Periods of vasodilation and constriction following
prolonged cold application to limit possible tissue injury
due to cold use

Cryotherapy:
• Cooling for too long may be detrimental to healing
• Ice application for 20 min. = decreased muscle
blood flow
– However, effects of ice application diminishes with
increased tissue depth
• Length of cooling required is dependent on
subcutaneous tissue thickness
– Recommended treatment times = 5-45 minutes

Cryotherapy:
• Ability to lower
tissue temperature
is dependent upon:
– Type of cold
applied to the skin
– Thickness of
subcutaneous fat
– Region of the body

Cryotherapy:
• Cold application results in:

– Decreased cell permeability and metabolism
– Decreased edema accumulation
• Should be continued in 5-45 minute
applications for up to 72 hours initially

Cryotherapy Techniques
• Cryotherapy techniques include
– Ice massage – Contrast baths

– Cold packs – Ice immersion
– Ice packs – Cryo-cuff
– Cold whirlpool – Cryokinetics
– Cold spray

Cryotherapy Techniques
• Application of cryotherapy produces a three-
to four-stage sensation
– Uncomfortable sensation of cold
– Stinging
– Burning or aching feeling
– Numbness
• Caution should be exercised when applying
intense cold directly to the skin
Ice Massage
• Often indicated with conditions
requiring stretching
• Appears to cool area faster than ice bag
application
• Procedures:
– Remove top 2/3 of paper or styrofoam
cupleaving 1”on bottom of cup as handle
– Apply using overlapping circular or
longitudinal stroke
– When skin is numb to fine touch treatment
ends(10-20 min)

Commercial Cold Packs
• Indicated for acute

musculoskeletal injuries
• Procedures
– Cold pack should be placed
against wet toweling and
covered with a towel to limit
environmental warming
– Mold cold pack around joint
– Treatment time required is
about 20 minutes
Ice Packs
• Indicated for acute injuries and
prevention of swelling following
exercise of injured area
• Procedures:
– Flaked or cubed ice in a plastic bag
large enough for the area to be
treated
– Applied directly to skin and held in
place by a moist or dry elastic wrap
– Can be molded to body part

Cold Whirlpool
• Indicated in acute and sub-acute
situations where exercise in cold
environment is desired
• Must be mindful of gravity
dependent position
• Procedures
– Fill appropriate size whirlpool with
cold water and flaked ice with temp.
at 50° to 60° F
– Use for massaging action

– Most intense application of cryotherapy
• Inability to develop thermopane (insulating layer of water)
due to water turbulence
• Convection provides for continuous circulation of cold water
• Results in significantly longer periods of temp. reduction
following treatment
• Additional care must be used with total body immersion
• With increased treatment area systemic effects are possible
– Equipment maintenance and cleaning are critical

Cold Spray and Stretch
• Flourimethane is used
• Acts as a counterirritant to block pain
• Cooling is superficial without
significant penetration
• Useful in treating trigger points
• Not effective in treating edema or
hemorrhaging
• Indicated in situations where cooling
and stretching are desired

• Procedure
– Spraying technique
• Same direction, even sweeps
• Work proximal to distal
• For trigger points, work from point to referred pain
area
• Affected muscles should be sprayed from the
affected area to the insertion
• Static stretching can be incorporated as you spray

Contrast Baths
• Used to treat subacute swelling
• Does not reduce edema through
“pumping” action as suggested
• Uses alternating hot (104-106o)
and cold (50-60o) immersions
• 3:1 or 4:1 heat:cold ratios have
been recommended
• Best used as a transition from cold
to heat
Cold Compression Units:
Cryo-cuff
• Used both acutely following
injury and post-surgically
• Applies both cold and
compression simultaneously
• Ice chills water which flows
into sleeve from cooler
• As cooler is raised pressure in
cuff is increased

Cryokinetics
• Combines cryotherapy with exercise
• Goal is to numb injured part (12-20 min) then work
toward achieving normal ROM through progressive
active exercise
• Numbness usually last for 3-5 min. at which point
ice is reapplied for 3-5 minutes until numbness returns
– Can be repeated five times
• Exercises should be pain free and progressive in
intensity concentrating on both flexibility and strength

Ice Immersion
• Ice buckets allow ease of application
(50-60o)
• Container should be large enough to
allow for movement of body segment
if being used for cryokinetics
• Body segment is subject to gravity-
dependent positions
• Cold pain may be more significant
than that experienced with cold pack
application

Thermotherapy:
Physiologic Effects of Tissue Heating
• Local superficial heating (infrared heat) is

recommended in subacute conditions for
reducing pain and inflammation through
analgesic effects
• During later stages of healing a deeper
heating effect is desirable and should be
achieved using the diathermies or
ultrasound
Thermotherapy
• Increase in temperature increases metabolism
– 13% increase in metabolism for each 1° C
• Superficial heat vasodilates vessels, which
increases capillary blood flow thus increasing
tendency toward formation of edema
– In mild or moderate inflammation increased capillary
blood flow causes an increase in supply of oxygen,
antibodies, leukocytes, and other nutrients and enzymes,
along with clearing of metabolites

Thermotherapy
• Used to produce an analgesic effect through

gate control
– Most frequent indication for the use
• Heat is applied in musculoskeletal and
neuromuscular disorders
• Increases the elasticity and decreases the
viscosity of connective tissue

Thermotherapy
• Produces a relaxation effect and a reduction in

muscle guarding by:
– Relieving pain
– Lessening hypertonicity of muscles
– Producing sedation
– Decreasing spasticity, tenderness, and spasm
– Decreasing tightness in muscles and related
structures
Thermotherapy
• Primary goals of thermotherapy include

– Increased blood flow
– Increased muscle temperature to stimulate
analgesia
– Increased nutrition to the damaged cells
– Reduction of edema
– Removal of metabolites and other products of
inflammatory process

Thermotherapy Techniques
• Warm Whirlpool
• Hydrocollator Packs
• Paraffin Bath
• Infrared Lamps
• Fluidotherapy

Warm Whirlpool
• Temperature Range
– Upper Extremity 98° -110° F
– Lower Extremity 98- 104° F
– Full body 98° - 102° F
• Time of application should be 15
to 20 minutes
• Caution is indicated in gravity-
dependent position in subacute
injuries
• Whirlpool maintenance

Warm Whirlpool
• Provides massaging effect and will stimulate
circulation
– Monitor for changes in edema
• Excellent post-surgical modality
– Increases systemic blood flow and mobilization
of body part
• Also noted to be one of the most abused
clinical modalities
Hydrocollator Packs
• Canvas pouches of petroleum
distillate
• Water temperature 170o
• 6 layers (1”) of toweling
recommended
• Don’t lie on top of hot pack!!
• Time of application should be
15 to 20 minutes

Paraffin Baths
• Mixture ratio of paraffin to
mineral oil (2 lbs : 1 gallon)
• Mineral oil reduces temp of the

paraffin to 126° F
• Extremity dipped into paraffin for

a couple of seconds then removed
to allow paraffin to harden

Paraffin Bath
• Repeat until 6 layers
have accumulated
• Wrap in a plastic bag
with several layers of
toweling
• Must exercise caution
with use to reduce chance
of burning patient

Fluidotherapy
• Dry heat modality that uses a
suspended air stream of corn husks
• Recommended temperatures vary
by body part & tolerance in a
range of 110° to 125°F
• Active and passive exercise is
encouraged during treatment
• Treatments are approximately 20
minutes

Fluidotherapy
• Medium allows for much higher
treatment temperatures
– Skin irritation and thermal shock limited
as well
– Mechano- and thermoreceptor stimulation
reduces pain sensitivity (counterirritation)
• Pressure may assist with edema
reduction
• Increases blood flow, sedates blood
pressure, accelerates biochemical
reactions

ThermaCare Wraps
• Cloth like material that
conforms to body
• Contains iron, charcoal,
table salt and water that
heat up when exposed to
oxygen
• Shown to be effective in
increasing tissue temp.
up to 2cm
Infrared Lamps
• Superficial tissue temperature can be
increased even though unit does not touch
patient
• Seldom used because of limited depth of
skin penetration (<1mm)
• Moist towels should cover the area to be
treated
• Distance from treatment area to lamp
should be adjusted according to treatment
time
• 20 inches = 20 minutes

Infrared Lamps
• Luminous and non-luminous infrared lamps are
classified as electromagnetic energy modalities
– Effects on tissue temperature are not related to conduction
• Non-luminous
– Metal coil wrapped around core of non-conducting material
• No longer used
• Luminous
– Tungsten filament and quartz red lamps

Counterirritants
• Not classified as infrared modalities
• Topically applied ointments that chemically
stimulate sensory receptors of the skin
• Contains
– Menthol
– Methyl salicylate
– Camphor
– Capsaicin
Counterirritants
• Ingredients have been shown to be effective in
reducing chronic pain and provide analgesic
effects
• Mechanism of pain relief not understood
– Application alone may trigger gate control theory
– May stimulate both noxious and thermal receptors
• Capsaicin is thought to have preferential action on C-fibers,
stimulating release and depletion of substance P
• Capsaicin may also affect synapses of spinothalamic tract

Summary
Indications for Cryotherapy
• Acute or subacute • Acute muscle strain
inflammation • Acute ligament sprain
• Acute pain
• Acute contusion
• Chronic pain
• Bursitis
• Acute swelling
• Tenosynovitis
• Myofascial trigger points
• Muscle guarding • Tendinitis
• Muscle spasm • Delayed onset muscle
soreness

Summary
Contraindications for Cryotherapy
• Impaired circulation •
• Peripheral vascular disease
• Hypersensitivity to cold
• Skin anesthesia
• Open wounds or skin conditions (cold
whirlpools and contrast baths)
• Infection

Summary
Indications for Thermotherapy
• Subacute and chronic • Muscle guarding
inflammatory • Muscle spasm
conditions
• Subacute Muscle strain
• Subacute or chronic
• Subacute Ligament
pain
sprain
• Subacute edema
removal • Subacute contusion
• Decreased ROM • Infection
• Resolution of swelling • Myofascial trigger points

Summary
Contraindications for Thermotherapy
• Acute musculoskeletal conditions •

• Impaired circulation
• Peripheral vascular disease
• Skin anesthesia
• Open wounds or skin conditions (cold
whirlpools and contrast baths)

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Chapter 4: Thermotherapy and

• Typically used to produce a local and/or

© 2009 McGraw-Hill Higher Education. All rights reserved.

• Transmission of heat occurs by three

*Conversion (involves change in one energy form to another)

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

• Cold application is often continued

• Hydrotherapy is also included (hot or cold)

© 2009 McGraw-Hill Higher Education. All rights reserved.

• Knowledge of the injury mechanism,

• Simple, efficient, and inexpensive means of

© 2009 McGraw-Hill Higher Education. All rights reserved.

• Physiologic effects are rarely the result of

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

• Increased blood flow will also result in increasing

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

• Local applications of cold decrease local

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

• Cold application results in:

© 2009 McGraw-Hill Higher Education. All rights reserved.

– Ice massage – Contrast baths

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

• Indicated for acute

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

• Local superficial heating (infrared heat) is

© 2009 McGraw-Hill Higher Education. All rights reserved.

• Used to produce an analgesic effect through

© 2009 McGraw-Hill Higher Education. All rights reserved.

• Produces a relaxation effect and a reduction in

• Primary goals of thermotherapy include

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

• Mineral oil reduces temp of the

• Extremity dipped into paraffin for

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.

© 2009 McGraw-Hill Higher Education. All rights reserved.