1. Chapter 4: Thermotherapy and Cryotherapy

2. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
Commercial cold packs
Ice packs
Cold whirlpool
Cold spray
Contrast Baths
Ice immersion
Cryo-cuff
Cryokinetics
Warm whirlpool
Hydrocollator packs
Paraffin baths
Infrared lamps
Fluidotherapy
© 2009 McGraw-Hill Higher Education. All rights reserved.

3. © 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

4. Mechanisms of Heat Transfer
Transmission of heat occurs by three mechanisms:
Conduction
Convection
Radiation
*Conversion (involves change in one energy form to another)
© 2009 McGraw-Hill Higher Education. All rights reserved.

5. 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

6. 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

7. 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

8. 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

9. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

10. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

11. 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

12. Effects of Tissue Temperature 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

13. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

14. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

15. Effects of Tissue Temperature 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

16. Effects of Tissue Temperature Change on Muscle Spasm
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

17. Effects of Tissue Temperature Change on Muscle Spasm
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

18. Effects of Tissue Temperature Change on Muscle Spasm
Nerve conduction velocity reduction also occurs with cold application
Decreases afferent discharge from cutaneous receptors
© 2009 McGraw-Hill Higher Education. All rights reserved.

19. Effects of Tissue Temperature 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

20. Effects of Tissue Temperature Change on Performance
Thermotherapy
Minimal or no effect on joint position sense, proprioception, and balance
© 2009 McGraw-Hill Higher Education. All rights reserved.

21. 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

22. Cryotherapy: Physiologic Effects of Tissue Cooling
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

23. Cryotherapy: Physiologic Effects of Tissue Cooling
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

24. Cryotherapy: Physiologic Effects of Tissue Cooling
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

25. Cryotherapy: Physiologic Effects of Tissue Cooling
Ability to lower tissue temperature is dependent upon:
Type of cold applied to the skin
Thickness of subcutaneous fat
Region of the body
© 2009 McGraw-Hill Higher Education. All rights reserved.

26. Cryotherapy: Physiologic Effects of Tissue Cooling
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

27. Cryotherapy Techniques
Cryotherapy techniques include
Ice massage
Cold packs
Ice packs
Cold whirlpool
Cold spray
Contrast baths
Ice immersion
Cryo-cuff
Cryokinetics
© 2009 McGraw-Hill Higher Education. All rights reserved.

28. 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

29. © 2009 McGraw-Hill Higher Education. All rights reserved.
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)
© 2009 McGraw-Hill Higher Education. All rights reserved.

30. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

31. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

32. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

33. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

34. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

35. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

36. © 2009 McGraw-Hill Higher Education. All rights reserved.
Contrast Baths
Used to treat subacute swelling
Does not reduce edema through “pumping” action as suggested
Uses alternating hot ( o) 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

37. 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

38. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

39. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

40. 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

41. Thermotherapy Physiologic Effects of Tissue Heating
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

42. Thermotherapy Physiologic Effects of Tissue Heating
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

43. Thermotherapy Physiologic Effects of Tissue Heating
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

44. Thermotherapy Physiologic Effects of Tissue Heating
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

45. Thermotherapy Techniques
Warm Whirlpool
Hydrocollator Packs
Paraffin Bath
Infrared Lamps
Fluidotherapy
© 2009 McGraw-Hill Higher Education. All rights reserved.

46. © 2009 McGraw-Hill Higher Education. All rights reserved.
Warm Whirlpool
Temperature Range
Upper Extremity 98° -110° F
Lower Extremity ° 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

47. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

48. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

49. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

50. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

51. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

52. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

53. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

54. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

55. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

56. © 2009 McGraw-Hill Higher Education. All rights reserved.
Counterirritants
Not classified as infrared modalities
Topically applied ointments that chemically stimulate sensory receptors of the skin
Contains
Menthol
Methyl salicylate
Camphor
Capsaicin
© 2009 McGraw-Hill Higher Education. All rights reserved.

57. © 2009 McGraw-Hill Higher Education. All rights reserved.
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
© 2009 McGraw-Hill Higher Education. All rights reserved.

58. Summary Indications for Cryotherapy
Acute or subacute inflammation
Acute pain
Chronic pain
Acute swelling
Myofascial trigger points
Muscle guarding
Muscle spasm
Acute muscle strain
Acute ligament sprain
Acute contusion
Bursitis
Tenosynovitis
Tendinitis
Delayed onset muscle soreness
© 2009 McGraw-Hill Higher Education. All rights reserved.

59. 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
© 2009 McGraw-Hill Higher Education. All rights reserved.

60. Summary Indications for Thermotherapy
Subacute and chronic inflammatory conditions
Subacute or chronic pain
Subacute edema removal
Decreased ROM
Resolution of swelling
Muscle guarding
Muscle spasm
Subacute Muscle strain
Subacute Ligament sprain
Subacute contusion
Infection
Myofascial trigger points
© 2009 McGraw-Hill Higher Education. All rights reserved.

61. Summary Contraindications for Thermotherapy
Acute musculoskeletal conditions
Impaired circulation
Peripheral vascular disease
Skin anesthesia
Open wounds or skin conditions (cold whirlpools and contrast baths)
© 2009 McGraw-Hill Higher Education. All rights reserved.