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 patients body, between various tissue/fluids
Cooling Agents
Transfer heat away from patients body

4. Therapeutic Application
Conduction
Convection
Conversion
Radiation
Evaporation

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
So
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.
Facilitation
Rarely used. (Rood)

26. Cryokinetics
Purpose:
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
Re-cooling
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
Cryoglobulinemia
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
Raynauds 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)
Raynauds 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
Hypertension
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
Burning
Aching
Analgesia, numbness

39. Cold Packs and Ice Bags

40. Cold Packs/ Ice Packs
Commercial
Silica or mix of saline/gel
Stored in freezer at 23 C
Moldable to patients 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
Inexpensive
Short use of clinicians 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