HYDROCOLLATOR PACKS

CONTRAST BATH
HYDROTHERAPY
• Advanteges
• Whirlpool ( thermo and mechano receptors)
• Fluidotherapy
• Heated air
• Electric heating pads

Effect of superficial heat on the tissue Therapeutic uses

• Relief of pain
• Encargement of healing
• Increase of range of motion
• Reflex heating
Energy Conversions

The ultimate goal of rehabilitation is to return the injured participant to activity, pain free and fully functional. The
rehabilitation process must focus on controlling pain and inflammation, and regaining normal joint range of motion
(ROM), flexibility, muscular strength, muscular endurance, coordination, and power.

Rehablitation
• rehabilitation “a set of measures that assist individuals who experience, or are likely to experience, disability to
achieve and maintain optimal functioning in interaction with their environments”.
• to enable persons with disabilities to attain and maintain their maximum independence, full physical, mental,
social and vocational ability, and full inclusion and participation in all aspects of life”.
  Therapeutic modalities and medications are used to create an optimal environment for injury repair by
limiting the inflammatory process and breaking the pain-spasm cycle.
 Use of any modality depends on the supervising PT’s exercise prescription, as well as the injury site, and type
and severity of injury.

INDICATION vs CONTRAINDICATION
• An indication is a condition that could benefit from a specific modality, whereas a contraindication is a condition
that could be adversely affected if a particular modality is used.

Gold Key
• In some cases, a modality may be indicated and contraindicated for the same condition. For example,
thermotherapy (heat therapy) may be contraindicated for tendinitis during the initial phase of the exercise program.
However, once acute inflammation is controlled, heat therapy may be indicated. Frequent evaluation of the
individual’s progress is necessary to ensure that the appropriate modality is being used.
•Various forms of energy in the environment impact us
• each day: the light from the sun, radio waves, heat from an oven, or cold from ice cubes. Each form of energy falls
under the category of electromagnetic radiation, and can be located on an electromagnetic spectrum based on its
wavelength or frequency.

Electromagnetic spectrum
• Electrical therapeutic modalities are part of the electromagnetic spectrum.
• The spectrum is divided into two major zones: the ionizing range and the nonionizing range. Regardless of the
range, electromagnetic energy has several common characteristics

Ionizing Range
• Energy in the ionizing range can readily alter the components of atoms (electrons, protons, and neutrons). This
radiation can easily penetrate tissue to deposit energy within the cells. If the energy level is high enough, the cell
loses its ability to regenerate, leading to cell death. Used diagnostically in x-rays (in dosages below that required for
cell death) and therapeutically to treat certain cancers (above the threshold), the level is strictly controlled and
monitored to prevent injury to the patient. It is not used physical therapists

Nonionizing Range
• Energy in the nonionizing range is commonly used in the management of musculoskeletal injuries. This portion of
the spectrum incorporates ultraviolet, visible, andinfrared light. Electromagnetic waves are produced when
temperature rises and electron activity increases. Ultraviolet light has a shorter wavelength than visible light;
therefore, it is undetectable by the human eye. This energy source causes superficial chemical changes in the skin
and is used to treat certain skin conditions. Sunburns are an example of excessive exposure to ultraviolet rays.
Wavelengths greater than visible light are called infrared light, or infrared energy. Infrared wavelengths closest to
visible light are called near infrared and can produce thermal effects 5- to 10-mm deep in tissue. Far infrared energy
results in more superficial heating of the skin (2 mm deep). Energy forms with much longer wavelengths are
collectively known as diathermy, and can increase tissue temperature through a process called conversion.
Microwave and shortwave diathermy are examples of this energy source.

Characteristics of Electromagnetic Energy

• Electromagnetic energy is composed of pure energy and does not have a mass.
• Energy travels at the speed of light (300 million meters per second).
• Energy wave forms travel in a straight line and can travel in a vacuum.
Transfer of Energy
• Electromagnetic energy can travel through a vacuum with no transfer medium. Energy moves from an area of high
concentration to an area of lower concentration by energy carriers, such as mechanical waves, electrons, photons,
and molecules. This energy flow in the form of heat involves the exchange of kinetic energy, or energy possessed by
an object by virtue of its motion, and is transferred via radiation, conduction, convection, conversion, or
evaporation.

Radiation
• Radiation is the transfer of energy in the form of infrared waves (radiant energy) without physical contact. All
matter radiates energy in the form of heat. Usually, body heat is warmer than the environment, and radiant heat
energy is dissipated through the air to surrounding solid, cooler objects. When the temperature of surrounding
objects in the environment exceeds skin temperature, radiant heat is absorbed. Shortwave and microwave
diathermy are examples of both radiant energy transfer, but also can heat by conversion.

Conduction
• Conduction is the direct transfer of energy between two objects in physical contact with each other. A differencein
temperature is necessary to initiate the movement of kinetic energy from one molecule to another, and the energy
moves from an area of high temperature to an area of lower temperature. Examples of conductive thermal agents
are ice bags, ice packs, moist hot packs, and paraffin.

Convection
•Convection, a more rapid process than conduction, occurs when a medium, such as air or water, moves across the
body, creating temperature variations. The effectiveness of heat loss or heat gain depends on how fast the air (or
water) next to the body is moved away once it becomes warmed. For example, if air movement is slow, air
molecules next to the skin are warmed and act as insulation. In contrast, if warmer air molecules are continually
replaced by cooler molecules (e.g., on a breezy day or in a room with a fan), heat loss increases as the air currents
carry heat away. Fluidotherapy and whirlpools are examples of therapeutic modalities that exchange energy by
convection.

Conversion
• Conversion involves the changing of another energy form (e.g., sound, electricity, or a chemical agent) into heat. In
ultrasound therapy, mechanical energy produced by high-frequency sound waves is converted to heat energy at
tissue interfaces. In microwave diathermy, high electromagnetic energy is converted into heat, which can heat deep
tissues. Chemical agents, such as liniments or balms, create heat by acting as counterirritants to superficial sensory
nerve endings, thus reducing the transmission of pain from underlying nerves.

Evaporation
• Heat loss also can occur during evaporation. Vapocoolant sprays, for example, spread a liquid over the skin surface.
The heat absorbed by the liquid cools the skin surface as the liquid changes into a gaseous state. Evaporation is also
the means by which the body cools itself on a hot day through the evaporation of sweat.

Factors Affecting Energy Transfer

• When electromagnetic energy is transmitted in a vacuum, it travels in a straight line. However, when traveling
through a physical medium the path is influenced by the density of the medium and the energy may be reflected,
refracted, or absorbed by the material, or it may continue to pass through the material, unaffected by its density.

Reflection
• Reflection occurs when the wave strikes an object and is bent back away from the material. An echo is an example
of a reflected sound. The reflection itself may be complete or partial.
Refraction
• is the deflection of waves because of a change in the speed of absorption as the wave passes between media of
different densities. If energy passes through a high-density layer and enters a low-density layer, its speed increases.
In contrast, if energy passes through a low-density layer to a high-density layer, its speed decreases.

Absorption
Absorption occurs when the wave passes through a medium and its kinetic energy is partially or totally assimilated
by the tissue. Any energy that is not reflected or absorbed by a tissue layer passes through the layer until it strikes
another density layer. It may again be reflected, refracted, absorbed, or transmitted through the medium. Each time
the wave is partially reflected, refracted, or absorbed, the remaining energy available to the deeper tissues is
reduced. This inverse relationship is called the law of
Grotthus- Draper:
The more energy absorbed by superficial tissues, the less is available to be transmitted to the underlying tissues.

Energy’s Effect on Tissue

To be effective, therapeutic modalities must be capable of producing the desired effects at the intended tissue
depth. When energy is applied to the body, the maximal effect occurs when energy rays strike the body at a right
angle (90). As the angle deviates from 90, some of the energy is reflected away from the target site, thereby
reducing the level of absorption. The cosine law (Figure) states that, as the angle deviates from 90, the energy varies
with the cosine of the angle:
Effective energy = Energy x cosine of the angle of incidence
With radiant energy, a difference of +/- 10 from the right angle is considered to be within acceptable limits

The inverse square law

Another law that affects energy
absorption is the inverse square law.
This law states that the intensity of
radiant energy striking the tissues is
directly proportional to the square of
the distance between the source of
the energy and the tissues:

E = ES/D².
ES = amount of energy produced by
the source
D² = square of the distance between
the target and the source
E = resulting energy absorbed by the
tissue

This means that each time the distance between the energy and the tissue is doubled, the intensity of the energy
received by the tissue is reduced by a factor of four.
CRYOTHERAPY
Cryotherapy describes multiple types of cold application. When cold is applied to skin (warmer object), heat is
removed or lost. This is referred to as heat abstraction. The most common modes of heat transfer with cold
application are conduction and evaporation. Cold application for less than 15 minutes causes immediate skin cooling,
cooling of subcutaneous tissue after a slight delay, and a longer delay in cooling muscle tissue . Depth of cold
penetration can reach 5 cm .

The magnitude of temperature change depends on:

• 1. Type of cooling agent (e.g., ice versus water)
• 2. Temperature difference between the cold object and tissue
• 3. Amount of subcutaneous insulation (fat)
• 4. Thermal conductivity of the area being cooled
• 5. Limb circumference
• 6. Duration of the application (2)

The greater the temperature gradient between the skin and cooling source, the greater the resulting tissue
temperature change. Likewise, the deeper the tissue, the longer the time required to lower the temperature.
Adipose (fat) tissue acts as an insulator and resists heat transfer; both heat gain and heat loss. The amount of
adipose tissue influences the degree and rate at which muscle is cooled, and conversely, return to its precooled
temperature.

Cold application leads to vasoconstriction at the cellular level and decreases tissue metabolism (i.e., decreases the
need for oxygen), which reduces secondary hypoxia. Capillary permeability and pain are decreased, and the release
of inflammatory mediators and prostaglandin synthesis is inhibited.

As the temperature of peripheral nerves decreases, a corresponding decrease is seen in nerve conduction velocity
across the nerve synapse, thus increasing the threshold required to fire the nerves.

PAIN DECREASE
The gate theory of pain hypothesizes that cold inhibits pain transmission by stimulating large-diameter neurons in
the spinal cord, acting as a counterirritant, which blocks pain perception. Because of the inhibition of nerves and
muscle spindle activity, muscles in spasm are relaxed, breaking the pain spasm cycle, leading to an analgesic, or pain-
free, effect.

Research also has shown that during ice application, a decline in fast-twitch muscle fiber tension occurs, resulting in
a more significant recruitment of slow-twitch muscle fibers, thereby increasing muscle endurance

Because vasoconstriction leads to a decrease in metabolic rate, inflammation, and pain, cryotherapy is the modality
of choice during the acute phase of an injury.
According to Starkey, the therapeutic application of cold ranges in temperature from 0° to 18.3°C (32 to 65°F) (1).
However, researchers have identified that maximaldecreases in localized blood flow can occur at temperatures
ranging from 12.83° to 15°C (55° to 59°F).

Forms
• ice bags (crushed or cubed),
• Commercial ice packs,
• ice cups (ice massage),
• cold water baths (immersion or whirlpool),
• and vapo-coolant sprays.
• Recent technology also has provided new forms of cold application such as the Cryocuff, or controlled cold therapy
(CCT) units.
**Cryotherapy is usually applied for 20 to 30 minutes for maximum cooling of both superficial and deep tissues.
**Ice application is continued during the first 24 to 72 hours after injury, or until acute bleeding and capillary leakage
have stopped, whichever is longer.

Cryokinetics.
Certain methods of cryotherapy also may be used prior to ROM exercises and at the conclusion of an exercise bout
(Box 7.2). Use of cold treatments before exercise is called cryokinetics. Cryokinetics alternates several bouts of cold
using ice massage, ice packs, ice immersion, or iced towels with active exercise. The injured body part is numbed
(generally 10 to 20 minutes of immersion), and the individual is instructed to perform various progressive exercises.
These exercises may begin with simple, non–weight-bearing ROM activities and progress to more complex, weight-
bearing activities. All exercise bouts must be pain free. As the mild anesthesia from the cold wears off, the body part
is renumbed with a 3- to 5-minute cold treatment. The exercise bout is repeated three to four times each session.
The session then ends with exercise if the individual is able to participate, or with cold if the individual is not able to
participate in practice.

Methods of cryotherapy
• ice massage, • ice and cryo packs,
• ice immersion and cold whirlpools, commercial gel and chemical packs,
• controlled cold compression units,
• vapo-coolant sprays.

With each method, the individual experiences four progressive sensations:

• cold,
• burning,
• aching,
• and finally analgesia
•Ice Massage
• Ice Packs and Contoured Cryocuffs

Contoured Cryocuffs
use ice water placed in an insulated thermos. When the thermos is raised above the body part, water flows into the
Cryo Pack, maintaining cold compression for 5 to 7 hours (Figure 7.6). Although more expensive than ice packs, these
devices combine ice and compression over a longer period without threat of frostbite.

•Ice Immersion
• Contrast Bath
• Commercial Gel and Chemical Packs
• Intermittent Compression Units
• Vapo-coolant Sprays

Intermittent cold-compression units

Intermittent Compression Units Intermittent cold-compression units like the Cryotemp use compression and
elevation to decrease blood flow to an extremity and assist venous return, thus decreasing edema. A boot or sleeve
is applied around the injured extremity. Cooled water is circulated through the sleeve. Compression is formed when
the sleeve is inflated intermittently. This is done for 20 to 30 minutes, several times a day, to pump edema fluid from
the extremity (Figure 7.9). During deflation, the patient can do active ROM exercises to enhance blood flow to the
injured area. The unit can be used several times a day, but should never be used with a suspected compartment
syndrome or fracture, or in an individual with a peripheral vascular disease or impaired circulation.