Introduction To Thermal Modalities

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Introduction ToThermal Modalities

• Russ Ridenhour, OTR, CHT

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What are thermal modalities?

• Hot packs
• Ultrasound
• Paraffin
• Fluidotherapy
• Whirlpool

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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

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Superficial Vs. Deep Heat

• 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

• Heat penetrates into tissue
• Ultrasound
• Depth of heating 5-6 CM

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How long does the heating effect last?

• Hot Packs - _at_ depth of 1 CM, 45-60 minutes

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Physiological effects of heat

• Vasodilatation
• Vasoconstriction
• Pain relief
• Increase tissue extensibility (before ROM)
• Increase blood flow
• Greenberg
• Phys Ther 1972

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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

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(Physiological effects of heat Cont. )

• 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.

• Promote healing
• because of the increase in blood flow
• Increase tissue extensibility

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Effects of Heat on Strength

• In 1st 30 minutes, strength decreases
• In next 1 1/2 hour, strength increases
• Endurance decreases when heated

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Some recent developments

• intracavity temp in knee after HP increased
  significantly and remained high 55 min.
  Weinberger et al.
  Scand J Rehab Med
• 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
  Horvath et al., J Clin Invest

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So what?

• Ice may be more beneficial
• than heat with
• inflammatory
• conditions

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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

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AOTAs position on modalities
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• ...may be used as an adjunct to purposeful
  activity to enhance occupational performance.
• Not an entry level skill
• requires post-professional education such as
  cont. ed, inservice training, or graduate
  education
• Training must be documented

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Recent AJOT article by Cornish-Painter,
Peterson, Lindstrom-Hazel

• ...of 100 occupational therapists who specialize
  in physical disabilities, most were using
  physical agent modalities in their practice
  however, their overall education for the use of
  physical agent modalities did not meet the AOTAs
  (1994) recommendations. AJOT 51681, 1997

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If you choose to use modalities, you should
expect scrutiny from PTs, peers, others.

• Are you applying the modality correctly?
• (thats usually the easy part)
• Do you know why you are using the modality?
• Are you fully aware of all the contraindications?

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WHAT TO TELL PATIENT

• Obtain informed consent
• Ask them to notify you immediately if they feel
  like it is getting too hot
• Give them a way to notify you if they start to
  have problems
• bell or buzzer

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CONTRAINDICATIONS

• Cancer
• non-diagnosed pain
• insensate skin
• Edema
• Acute injury
• Circulatory impairment
• atrial or venous thrombosis
• confused or disoriented pt
• Open wounds

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What to document

• Your explanation of risks and benefits
• Informed consent
• Sensory exam
• That you have asked about all the possible
  contraindications

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Indications for Hot Packs

• Pain from muscle tears, ligament strains or
  sprains
• Muscle or tendon tightness
• Joint stiffness

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Hot Packs

• Hydrocollator water temperature _at_ 1600-1700
• 1 1/2 or 6 layers of toweling
• Wash towel which touches pts skin during
  treatment
• Never lay pt supine on HPs
• 20 min. treatment
• story of lengthy HP treatment

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Hot Packs Cont.

• Which size HP to use
• More pts burned
  with HP than
  anything else

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Paraffin Bath

• Frequently used with arthritis
• Hand is immobile during treatment
• Useful when motion is not indicated
• Paraffin temp - 1300
• Have pt wash hands

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• Pt dips hand 6-10 times
• While dipping, keep fingers still
• Dip quickly, then lift until paraffin stops
  dripping

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• It is mandatory that you check temp. before every
  use of paraffin bath
• if gt 1300 dont use the machine
• Wrap in plastic
• 10-20 minute treatment time

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• 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?

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Types of pts who may benefit from paraffin

• Arthritis
• simultaneous stretch heat
• stiff PIPJ
• Conditions where motion is not indicated
• Schleroderma

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Indications for fluidotherapy

• Joint stiffness
• Muscle or tendon tightness
• Spacticity
• Pain in the hand

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Fluidotherapy

• 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

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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)

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Tips while using fluidotherapy cont.

• Make sure staff monitor temp. of unit.
• if gt 1180 take the pt out
• The manufacturer states that the unit is a
  sterile environment
• Dont 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

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• A splint or device to stretch joint can be
  applied during fluidotherapy

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Fluidotherapy Controls

• Air speed 0-100
• Pulse time
• P11 sec on,1 sec off
• P22 sec on, 2 sec off
• P3, P4, P5, P6

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Good test questions

• What is the maximum acceptable temp. of
  fluidotherapy?
• 1180
• How much toweling should be used with HPs?
• 1 1/2
• AOTAs position paper on the use of modalities
  states that modalities can be used as an
  adjunct to or in preparation for what?
• Purposeful activity

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Test ?s cont.

• When should you check the temperature on a
  paraffin bath ?
• before the treatment
• What is the maximum acceptable temperature for a
  paraffin bath treatment
• 1300
• Does a heat modality cause initial vasodilatation
  or vasoconstriction?

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Test ?s cont.

• Vasodilatation
• List 3 contraindications for heat modalities
• insensate skin, diminished skin circulation,
  cancer, undiagnosed pain

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References

• Abramson DI others Effect of paraffin bath
  hot fomentations on local tissue temperatures,
  Arch Phys Med Rehabil 4587, 1964.
• Abramson Dl and others Changes in blood flow.
  oxygen uptake and tissue temperatures produced by
  the topical application of wet heat. Arch Phys
  Med Rehabil 42305. 1961.
• Borrell RM and others Fluidotherapy evaluation
  of a new heat modality. Arch Phys Med Rehabil
  5869. 1977.
• Borrell RM, Parker R, Henley EJ, Masley D, et al.
  Comparison of in vivo temperatures produced by
  hydrotherapy, paraffin wax treatment,
  Fluidotherapy. Phys Ther 60 69-71. 1980.
• Chastain PB The effect of deep heat on isometric
  strength. Phys Ther 58543.1978.
• Cobbold AF and Lewis Blood flow to the knee
  joint of the dog effect of healing. cooling. and
  adrenaline. Phvsiol 132379,1956.

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References Cont.

• Cornell-Painter C,Peterson C, Lindstrom-Hazel D.
  Skill Acquisition Competency Testing for
  Physical Agent Modalities Use. AJOT 518, 1997.
• Greenberg R. The Effects of Hot Packs Exercise
  on Local Blood Flow. Physical Therapy 523,
  1972.
• Hawkes J, Care G, Dixon JS, Bird HA, et al.
  Comparison of three physiotherapy regimens for
  hands with rheumatoid arthritis. Brit Med J.
  291 1016. 1985.
• Henricson AS, Fredriksson K, Persson I, Pereira
  R, et al. The effect of heat stretching on the
  range of motion of hip. J Ortho Sports Phys
  Ther. 6 110-115. 1984.
• Hovarth, SM Hollander, JL Intraarticular
  temperature as a measure of joint reaction. J
  Clin Invest 28 469, 1949.
• Knight KL Londeree BR Comparison of blood flow
  in the ankle of uninjured subjects during
  therapeutic application of heat, cold,
  exercise, Med Sci Sports Exerc 1276, 1980.

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References Cont.

• Lehmann JF others Effect of therapeutic
  temperatures on tendon extensibility, Arch Phys
  Med Rehabil 51 481, 1970
• Lehmann JF others Temperature distributions
  in the human thigh, produced by infrared, hot
  pack microwave applications. Arch Phys Med
  Rehabil 47291, 1966
• Lehmann JF, Watten CG, Scham SM Therapeutic
  heat cold, Clin Orthop 99207, 1974.
• Mense S Effects of temperature on the discharges
  of muscle spindles tendon organs, Pflugers Arch
  374159, 1978
• Warren CG, Lehmann JF, Koblanske JN. Heat
  stretch procedures An evaluation using rat tail
  tendon. Arch Phys Med Rehab. 57 122-126. 1976.
• Weinberger, Fadilah, Lev Pinkhas
  Intra-Articular temperature measurements after
  superficial heating, Scand J Rehab Med 2155-57,
  1989.

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