Guided Reading Questions for Hot and Cold Modalities – Flashcards
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What is a physical agent modality (PAM)?
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- Interventions or procedures that produce a response in soft tissue through the use of light, water, temperature, sound, electricity, or mechanical devices - Applied to modify specific client factors and prepare clients for engagement in occupations when neurological, musculoskeletal, or skin conditions limit occupational performance
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What are the four categories of physical agent modalities?
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- Superficial thermal agents: Hydrotherapy/whirlpool, Cryotherapy, Fluidotherapy, Hotpacks, Paraffin - Deep thermal agents: therapeutic ultrasound, phonophoresis - Electrotherapeutic agents - Mechanical devices
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What are three main reasons we provide physical agent modalities as part of the preparation for engaging more successfully in occupational activity?
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- To help increase soft tissue extensibility, reduce pain and inflammation, and improve muscle performance to help clients more successfully engage in occupational activity
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What three factors are required in determining whether an OT should use a physical agent modality?
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1. AOTA's position on the use of physical agent modalities 2. Personal competency in the specific physical agent 3. Federal, state, and institutional rules and guidelines surrounding use of physical agents in occupational therapy practice
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What is AOTAs position on the use of physical agent modalities?
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- Physical agents are preparatory and are to be used by OT practitioners before or during therapeutic activities that ultimately enhance engagement in occupation - "the exclusive use of physical agents as a therapeutic intervention without application to occupational performance is not considered occupational therapy - OT who uses a physical agent modality must always do so relative to an occupational outcome
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When is use of a physical agent modality NOT considered occupational therapy according to the AOTA position paper? Use the case in Definition 19-1 to further your understanding.
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- OTs who use physical agents without any application to occupational performance could be viewed by regulatory agencies as practicing outside the scope of OT
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What does the Occupational Therapy Code of Ethics and Ethics Standards indicate about competence and how does this information relate to your understanding of competence in physical agent modalities?
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- AOTA states that physical agents may only be applied by OT practitioners who have documented evidence of o possessing the theoretical background and technical skills for safe and competent integration of the modality into an OT intervention plan - "OT personnel shall provide OT services that are within each practitioner's level of competence and scope of practice"
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If you move to a new state what do you need to do or know in order to provide physical agent modalities as part of your practice?
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- Contact your respective state regulatory board to obtain the most current information and be able to document and defend their education and training in meeting regulatory requirements
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What is the evidence put forth by peer reviewed literature that discusses the efficacy of physical agent modalities?
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- Physical agent modalities is an area that requires more research - Evidence in peer reviewed literature is contradictory when it comes to the efficacy of most physical agents
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What are the three components of evidence based practice according to David Sackett?
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- Current best evidence - Clinical expertise - Patient choice
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What factors can slow the healing process?
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- Advanced age - Presence of foreign objects - Infection - Poor nutrition - Medications
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What is the purpose and some of the symptoms that occur during the acute inflammatory phase?
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- Inflammation is the initial response to tissue injury; both vascular and cellular - Body is working to control blood loss and to clean the wounded area - Inflammatory response may be associated with changes in skin color (red, blue, or purple), temperature (heat), edema (swelling), sensation (pain), and loss of function
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How long does the acute inflammatory phase last?
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- A couple of days to a couple of weeks
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What is the purpose of physical agents in the acute inflammatory phase?
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- Physical agents that help manage pain and control excessive edema are cryotherapy and pulsed wave ultrasound
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Do we want to eliminate ALL inflammation and edema during the acute inflammatory phase? Why?
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- No, some amount of inflammation and swelling are needed to prepare the wound for the proliferative phase of healing
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Why is excess edema problematic?
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- It is painful and can reduce blood flow, which is critical for bringing nutrients to healing cells
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What category of physical agent modality is contraindicated during the acute inflammatory phases and why?
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- NOTE: SAFETY MESSAGE: - The use of heat during the active inflammatory phase of healing is contraindicated because it causes physiological responses that increase edema
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What is the purpose of the proliferative phase?
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- To repair the damaged tissue site
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How long does the proliferative stage last? (when do you think it starts? )
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- Once the injured area is clean, the body starts working on repairing the damaged tissue site - May take up to a few weeks to complete
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What are examples of physical agent modalities that speed new tissue formation?
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- Therapeutic ultrasound and electrical stimulation
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How long does the maturation phase last?
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- It can take up to 2 years to complete
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What is occurring during the maturation phase?
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- Final stage where collagen fibers in the wounded tissue are produced, broken down, changed, and reoriented to become what we know as scar tissue
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What is the texture and strength of the matured tissue as the maturation phase progresses?
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- Only about 80% as strong as the original tissues strength - Relatively inelastic and "tight" compared to the original tissue
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What are some examples of physical agent modalities that improve connective tissue extensibility in preparation for tissue stretching?
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- Superficial heating agents and the use of continuous wave ultrasound that provides deep heat
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What is included in the documentation of a physical agent treatment?
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- Physical agent applied and treatment parameters - Site of application or placement - Treatment duration - Physiological responses elicited from treatment - Subjective responses from the patient, such as tolerance, reaction, and clinical effectiveness - Reason for using the physical agent with respect to the ultimate functional goal
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What information (3 things) should be provided to the patient prior to administration of the physical agent?
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- Inform patient as to the procedure, expected outcome, and subjective sensation that the patient may feel during the treatment
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When should skin integrity be assessed in relation to application of a physical agent modality?
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- Prior to administration of physical agents and immediately following the intervention
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What is thermotherapy?
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- The therapeutic application of heat
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How deep do superficial thermal agents penetrate? (look at a ruler/measuring tape so you can think about how deep this is)
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- Up to 1 cm
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Identify the types of superficial-heating agents
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- Warm whirlpool baths - Fluidotherapy - Hot packs - Paraffin
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How deep do deep-heating agents penetrate the tissue with heat?
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- Up to 5 cm
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What is a commonly used deep heating agent?
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- Therapeutic ultrasound
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What is the analgesic effect of heat?
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- It reduces pain symptoms - Heat acts selectively on free nerve endings, tissues and peripheral nerve fibers, which directly or indirectly reduces pain, elevates pain tolerance, and promotes relaxation
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What is the vascular effect of heat?
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- Aid in pain relief and in decreasing muscle spasm and spasticity - As the temp. Of the tissue elevates, substances such as histamines are released into the bloodstream, resulting in vasodilation - This increased blood flow reduces ischemia, muscle spindle activity, tonic muscle contractions, spasticity, and pain
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What is the metabolic effect of heat?
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- Influence tissue repair and aid pain relief p. 565
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What is the connective tissue response to heat?
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- Refers to the fact that biological tissues are more easily stretched after heating - Collagen is the primary component protein of skin, tendon, bone cartilage, and connective tissue - Those tissues containing collagen can become shortened because of immobilization or limited range of motion as a result of weakness, injury, or pain - Improvement in the properties of collagen and extensibility of tissues occurs when heat is combined with passive or active mobilization and /or engagement in occupation - This ultimately results in reduced joint stiffness and increased ROM
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What is cryotherapy? Is it superficial or deep?
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- Also called cold therapy: is the therapeutic application of physical agents to lower tissue temperatures - Superficial thermal agent because it moves heat out of the body
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How deep does cryotherapy affect the tissue?
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- 2 cm
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What is the analgesic effect of cold?
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- Influences pain symptoms - Cold elevates the pain threshold through counterirritation and by reducing nerve conduction velocity in the more superficial sensory nerves
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What is the vascular effect of cold?
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- Include both vasoconstriction (when cold is applied for less than 15 minutes) and vasodilation (when cold is applied for longer than 15 minutes) - Short term application of cold therapy can help reduce edema
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What is the metabolic effect of cold?
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- Influence inflammation and tissue repair - Application of cold therapy slows down the metabolic processes of tissue repair and should therefore be used thoughtfully - We do not want to interfere with the normal healing process, but cold therapy can be useful to control excessive inflammation and edema in the very early stages of healing
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What is the neuromuscular effects of cold?
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- Influence muscle tone - Cold therapy can temporarily reduce spasticity in patients with upper motor neuron lesions
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Mild application of heat increases the surface how many degrees Fahrenheit?
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4-5 degrees F (2.2-2.78 degrees C)
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What is the expected benefit of mild heat?
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Relaxation and pain relief
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Moderate to vigorous heat dose increases the skin surface temperature by how many degrees fareinheit?
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A moderate dose of heat causes an increase in tissue temperature of 6 degrees F (3.3 degrees C). A vigorous dose elevates the tissue up to 14 degrees F (9.78 degrees C)
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What is the therapeutic benefit of a moderate to vigorous heat dose?
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Moderate to vigorous doses of what are needed to cause vascular, metabolic, and connective tissue responses
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What is the average skin surface temperature?
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91 degrees
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What two body function and process skill must a person have to whom you are applying heat?
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Heat be applied only to patients who can feel the sensation of heat and only to patients who can understand and communicate to the therapist if the heating process becomes uncomfortable
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Explain how adipose tissue affects the required time period of heating to achieve therapeutic effect.
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temp of whirlpool bath
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99-104 degrees, and should never exceed 110 degrees
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Fluidotherapy: temp
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105-118
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Fluidotherapy: advantages
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Ease of implementation, can actively exercise UE as the tissue heats up, therapist can provide AA/PROM, dry particles can provide desensitization therapy during the heating process
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Fluidotherapy: contraindication
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open wound
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Fluidotherapy: tx time
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20 minutes
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Fluidotherapy: what is it?
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Fine particles of organic cellulose blown around in a hot air stream inside a containing unit to heat an extremity. The force of air and particles circulating within the machine can be graded via the blower speed. Dry whirlpool bath
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can people with open wounds use whirlpool
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Although the book indicates open wounds are contra-indicated for a whirlpool, the fact is sterile whirlpool is a very effective and widely used treatment to debride and clean open wounds. The disadvantage here is there is a lengthy cleaning process following the whirlpool that is required. These whirlpools are performed at lower temperature close to body temperature as this is an acute phase and heat is not indicated
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hot pack: A "hot pack cover" is equivalent to how many layers
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3-4 layers (1 towel, folded twice)
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contraindications whirlpool bath
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Significant edema (the heat, and the position of the client increases edema), risk of spreading infection.
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length of time whirlpool bath
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20 mins
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advantages to whirlpool bath
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Can actively exercise the extremity the extremity as it heats, therapist can provide AA/PROM, and the temperature of the bath can be controlled
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what is Whirlpool bath
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A tank equipped with a water circulating mechanism that draws water out and pushes it into the tank at varying speeds
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paraffin: number of dips
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8-10 dips
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paraffin: What is the hand dipped in the paraffin wax wrapped/covered with
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Wrapped in a plastic bag, followed by a towel/oven mit
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paraffin: advantages
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Easily conforms to the hand, provided even distribution of heat to all parts of the hand
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paraffin: what does the therapist need to do before having the patient dip?
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Check the temperature to ensure safe, and avoid burns. Ask client to wash entire extremity with soap and water prior to treatment
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paraffin: disadvantages
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Hands need to remain still during treatment (limits AA/AROM)
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paraffin: contraindications
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open wounds
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What are the three mechanisms of transferring heat out of the body for purposes of cooling? And provide examples of each
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Through conduction or convection, & evaporation Conduction Cryotherapy EX: cold pack Convection Cryotherapy EX: immersing an extremity in a cold water bath Evaporation Cryotherapy EX: therapeutic cold sprays applied to the body in the form of liquid absorb heat from the skin and then evaporate
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What is the difference in applying a cold pack over a wet towel vs applying it over a dry towel?
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Ice packs covered with wetted material will cool superficially tissues at a faster rate and may not be tolerated well by patients who need deeper tissues cooled
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normal color response to cold
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Normally turns the skin a pink or light red color
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cryotherapy precautions
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Peripheral vascular disease or any circulatory compromised area Cold sensitivity or Raynaud's phenomenon Multiple myeloma, leukemia, or systemic lupus (cryoglobinemia is a disorder of abnormal protein formation that can lead to ischemia in these individuals) Cold urticaria/intolerance; can occur with rheumatic diseases, or following crush injuries or amputations
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abnormal response to cold
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If the skin turns bright red, white, pale, or grayish yellow or develops welts, discontinue immediately
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paraffin: temp?
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120-130
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paraffin: what is it?
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Thermostatically controlled heating unit filled with a commercial mixture of paraffin wax and mineral oil
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hot pack: what happens when the cover is damp?
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More heat is transferred the hot pack to the body. So padding she be rotated and have time to dry, or more layers of padding will be needed to ensure that the patient does not get burned.
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What things does the therapist consider when selecting which superficial heating agent to use?
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hot pack: How many layers of toweling
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6-8
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hot pack: disadvantages
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Heaviness of the hotpack, difficult to conform to small areas (such as hand). Also, the area has to be nonmobile, and covered (limites AA/AROM
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hot pack: advantages
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Simple to use, widely available, can heat large surfaces
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hotpack: tx time
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20 minutes
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hot pack: typical temperature
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104-113
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HOt packs: where are they stores?
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The hot pack is wrapped with dry padding, and with appropriate towel use
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superficial thermal agents contraindications
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Impaired sensation caused by skin graft or scar Tumors or cancer Advanced cardiac disease (body inadequately dissipates heat) Acute inflammation or acute edema Deep vein thrombophlebitis Pregnancy (systemic effects of circulating blood on fetus are unclear) Bleeding tendencies Infection Primary repair of tendon or ligament Semicoma or impaired cognitive status Rheumatoid arthritis: vigorous dosages of heat can exacerbate joint inflammation
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hot pack: What temperature should the thermometer read when checking the water?
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165 degrees
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hot pack: where are they stored?
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Stored in a thermostatically controlled container of hot water called a hydrocollator
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hot pack: what are they?
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canvas cases of materials
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What are the three types of mechanisms for heat transfer and provide example of modalities for each?
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Conduction Convection Radiation
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fluidotherapy: client must do what before tx?
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wash hands with soap and water
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superficial thermal agents precautions
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Edema Diminished sensation Compromised circulation Use of anticoagulant medications
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cryocuff/
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Cold therapy machines circulate cold water through an insulated cooler and special sleeve that covers the body part
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What are two inexpensive cold pack alternatives for home use?
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Unopened frozen bag of peas; can also be made by combining three parts water to one part isoprophyl alcohol in a plastic zip-seal bag and freezing
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What should be placed between the patient and the cold pack?
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Cold packs should always be covered with a material such as toweling or a pillow case
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cold pack: tx time
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Up to 20 minutes, but the patient should be monitored for signs of cold intolerance or tissue damage
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cold pack: advantages
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Inexpensive, are easy to find or make, and can cover large areas
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cold pack: disadvantages
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Difficult to conform to smaller, multisurface areas such as the hand
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What are the stages of sensation experienced during the ice massage? Cold, burning, aching, and then numbness (once numb, should be discontinued)
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- Cold, burning, aching, and then numbness (once numb, should be discontinued)
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ice massage: tx time
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Bc tissues are cooled so rapidly during ice massage, this treatment generally takes no longer than 10 minutes, and treatment time should be guided by how the patient feels
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Ice Massage: Advantages
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- Ease of use, little expense, and quick inducement of analgesia in appropriate tissues
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Ice Massage: What do you do to protect the patient's clothing during this technique?
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- Ice massage can be messy as the ice melts, so protect your patients clothing with dry toweling during this procedure
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Ice Massage: Disadvantages
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- Not tolerated well by people who do not want to endure the sensations of burning and aching prior to reaching the stage of numbness
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ice massage: What is the technique and when is it used?
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Ice massage requires holding ice directly against the skin and moving it in slow circles over the target tissue. This technique is normally used for cooling small areas such as tendon insertion sites and hyper-irritable muscle spots to produce an anastalgic effect
