Heat Therapy
In contrast to deep heating modalities, superficial heating modalities
usually do not heat deep tissues, including muscles, because the subcutaneous
layer of fat beneath the skin surface acts as a thermal insulator and inhibits
heat transfer. Additionally, increased Surface blood flow from superficial
heating causes a cooling reaction as it removes the heat that is applied
externally. In general, the transfer of heat (whether the purpose is heating or
cooling) often is classified into 3 general types of heat transfer (ie,
conduction, convection, conversion).
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Several factors determine the extent of the physiologic response to heat,
including the following:
- Level of tissue temperature (usually 40-45°C)
- Duration of the tissue temperature increase
- Rate of increase in tissue temperature
- Size of the area being treated
Heat Therapy Methods
Conductive heating is usually a simple treatment that can be taught to the
patient for independent home use. The disadvantages of this treatment form include
potential burns, difficulty with application to regions exhibiting abnormalities
(eg, foot), and the skin-drying effect (with the exception of
paraffin or water media).
Hot packs or hydrocollator packs contain silicate gel in a cotton bag. These
packs are placed in a hot water tank, which is thermostatically controlled at
71.1-79.4°C. The silicate gel absorbs a large quantity of water and has a high
heat capacity.
Use of the hydrocollator
Hot packs are applied over layers of towels for 20-30 minutes. Most of the
heat transfer from the hot pack to the patient is by conduction. Increasing the
towel thickness reduces the heat flow and produces an intentional slowing in the
temperature rise. Acceleration of heat transfer occurs if the hot pack leaks
into the towel. The patient never should lie on the hot pack, as the body weight
could squeeze hot water out of the pack into the towel and potentially cause a
burn.
The maximum skin temperature is obtained after 8 minutes, followed by a
reduction in temperature due to increased blood flow. Repeated application of
hot packs may prolong the period of temperature elevation but does not alter the
temperature distribution.
Other forms of hot packs include the
Flaxseed microwave pack
stimulation/heating), rubber hot water bottle, and electric heating pad. Heat
transfer is enhanced if the pad is moist or if the heated part is wrapped in
moist material. The complications of electric heating pad include shock hazard
if the device is not insulated properly and burns if the patient falls asleep
lying on the pad. Heat output increases over time until equilibrium is achieved.
Warning *** heat may be sufficiently analgesic to produce burns.
Uses of Hot Packs
Indications for the application of hot packs may include painful muscle
spasms, abdominal muscle cramping, menstrual cramps, and superficial
thrombophlebitis. Hospitalized patients receive circulated warm-fluid hot packs
to minimize the potential for burns due to prolonged superficial heating
application in sensory impaired patients or mentally challenged patients.
Chemical packs often are available in containers which, when properly
manipulated, allow previously separated ingredients to mix, thereby producing an
exothermic chemical reaction that causes heat production.
Warm Air Treatment
This is a form of convective heating that uses a bed of uniform
finely divided round solids, such as glass beads, into which thermostatically
controlled warm air is blown to generate a semifluid warm mixture. Part of the
limb or hand/foot can be immersed for superficial heating. This technique
applies dry heat, and the temperature is equivalent to the hot air that is blown
into the bed of beads. The usual treatment temperature range is 45.6-47.8°C.
Uses of this therapy may include pain relief in arthritic conditions of small
joints, joint mobilization following trauma/mobility, and analgesia/sedation in
young patients undergoing exercise programs with painful and contracted joints
due to sickle cell anemia.
Hydrotherapy
Hydrotherapy can include total immersion in a large hot tub or Hubbard tank.
Partial immersion is available for upper or lower extremities by whirlpool
baths. As hydrotherapy also may be used in treating infected draining wounds,
the equipment must be sterilized between uses. The water is agitated, and the
size of the tank determines the capacity (the entire body or just the upper or
lower extremities). For total body immersion in water, the temperature should
not exceed 40.6°C. Partial immersion of a limb should have a maximum temperature
of 46.1°C. The treatment time is limited to 20-30 minutes each session. As a
precaution for total body immersion, oral temperature should be observed with
water temperatures over 37.8°C to prevent a rise of body core temperature. With
total body immersion, heat loss occurs primarily through the head and neck;
therefore, the heat regulatory mechanism is impaired significantly.
Total body immersion has a relaxing effect and may
predispose the patient to hypotension due to peripheral blood pooling secondary
to vasodilatation of all 4 limbs.
Moist air cabinet
Another convection modality is the moist air cabinet. Air saturated with
water vapor at a controlled temperature is blown over the patient, causing
superficial heating over a large area. The temperature distribution in this
modality provides heating of skin and superficial tissue. This modality is used
most commonly for back muscle spasms and polyarticular arthritic conditions. The
recommended temperature maximum is 40.6°C.
Contrast Baths
Contrast baths provide a method of therapeutic hyperemia for management of
rheumatoid arthritis or sympathetically mediated pain (eg, rheumatoid arthritis
of distal joints, hands, feet; prolonged ankle swelling after an ankle
sprain/strain in refractory joint effusions). A differential of approximately
25°C exists between the hot and cold water. The hot water is at a temperature of
40.6-43.3°C. The cold water temperature is maintained at 15-20°C. The greatest
hyperemia response is produced by a 10-minute hot water immersion followed by
cold water for 1 minute. The cycle continues with hot water immersion for 4
minutes and cold water for 1 minute; this 4:1 cycle is repeated for a total of
30 minutes at each physical therapy appointment or for each home-based
self-treatment session. Other approaches to convective heating include
water-based exercise and spa therapy (balneotherapy).
Conversion Heating
Radiant heat therapy is a type of conversion heating. The high-energy photons
penetrate the tissues, and this energy is converted to heat. Because photons of
longer wavelengths process less energy, penetration is more superficial; shorter
wavelengths have a greater therapeutic benefit. The therapeutic radiant
heat-producing temperature rise in tissues ranges from the spectrum of far
infrared to visible yellow. Longer wavelengths of light from green to
ultraviolet produce photochemical reactions that do not raise tissue temperature
significantly. Most other commercially available radiant light sources produce
infrared with some visible light. These lamps contain heating elements of
Carborundum (silicon carbide), special quartz tubes, or metal alloys. The higher
energy photons are produced by shorter wavelength radiant heat, resulting in a
greater penetration of superficial tissue.
The most common indications for radiant heat therapy include muscle spasms
from underlying joint/skeletal conditions, rheumatic joints where direct heating
of the joint is contraindicated, and treatment of superficial skin breakdown in
the intertriginous areas.
A treatment time of 20-30 minutes is recommended, with the maximum effect
occurring at a minimum of 20 minutes. The radiant energy source is positioned at
15-24 inches (38.1-61 cm) from the treatment site. The intensity is controlled
by the light source, distance, type/quality of reflector, and air movement. With
heat lamps, guidance concerning treatment time is given by the patient's
subjective feeling of warmth. The conventional single heat cradle with an output
of 300 watts is not likely to increase body temperature; however, a double
cradle could. Patients also could receive increased radiation after an hour of
treatment time.
Infrared radiation can be used for reflex vasodilatation where vasospasm is
present. Because of the photochemical effect of lower energy ultraviolet
photons, this radiant energy is used most effectively for treatment of psoriasis
and other dermatologic conditions.
Contraindications To Superficial Heat Application
Superficial heat modalities are contraindicated in the following situations:
Paraffin baths or fluidotherapy should not be used in open wounds that are
either clean or infected.
Hydrotherapy is contraindicated in patients immediately following surgery, as
a healing wound should be kept dry.
Special precautions should be used for therapy to be provided in a Hubbard
tank for patients with either a tracheostomy or ostomy.
Radiant heat should not be used in patients with the following conditions:
Photosensitivity
Acute inflammation or hemorrhage
Bleeding disorder
Decreased sensation
Because total immersion in a Hubbard tank elevates core body temperature,
patients with the following conditions that generate temperature-sensitivity
should avoid this heating modality:
Multiple sclerosis
Adrenal suppression or failure
Systemic lupus erythematosus
Pregnancy
Cold Versus Heat Therapy
Both heat and cold modalities can be used effectively in various clinical
conditions. Many situations lend themselves to use of these diverse modalities
to take advantage of known biologic effects for managing certain ailments.
The similarities of these 2 modalities include the following:
Decreased muscle spasm secondary to musculoskeletal pathology or nerve root
irritation
Cold effectively decreases spasticity of upper motor neuron etiology; heat
reduces spasticity, but the effects are short-lived and ineffective for muscle
re-education.
Both heat and cold modalities cause analgesia.
The following examples illustrate the significant differences in the
physiological effects between therapeutic heat and cold treatments:
A longer time is necessary for cooled muscle to return to normal temperature.
Because application of heat increases blood flow, a heated muscle returns to
normal temperature after a few minutes.
The application of heat for relief of muscle spasm is secondary to muscle
hyperemia, which decreases muscle spasm-induced ischemia/pain and interrupts
this vicious cycle.
Increased tissue metabolism occurs with temperature elevation; reduced
metabolism with cold modalities.
Heated muscle tissue can sustain a contraction for a shorter period of time;
cooling to approximately 27°C increases the ability of muscle to sustain
contraction.
Blood flow increases with heat and decreases with cold.
The tendency to bleed increases with heat and decreases with cold.
Formation of edema is facilitated by heat and decreased by cooling.
Immediate cooling of burns is beneficial; however, frostbite is treated by
quick warming.
Joint stiffness is decreased with heating but increased with cold.
Due to blood pooling, orthostatic hypotension is produced by application of
heat to large parts or all of the body. With cold treatment, hypotension is
decreased secondary to vasoconstriction.
Fedorczyk J: The role of physical agents in modulating pain. J Hand Ther 1997
Apr-Jun; 10(2): 110-21[Medline].
Grana WA: Physical agents in musculoskeletal problems: heat and cold therapy
modalities. Instr Course Lect 1993; 42: 439-42[Medline].
Helfand AE, Bruno J: Therapeutic modalities and procedures. Part I: Cold and
Heat. Clin Podiatry 1984 Aug; 1(2): 301-13[Medline].
Lehman JF, De Lateur BJ: Therapeutic heat. In: Therapeutic Heat and Cold, 4th
ed. Baltimore, MD: Williams & Wilkins; 1990:417-581.
Lehman JF, De Lateur BJ: Cryotherapy. In: Therapeutic Heat and Cold, 4th ed.
Baltimore, MD: Williams & Wilkins 1990:590-632.
Oosterveld FG, Rasker JJ: Effects of local heat and cold treatment on surface
and articular temperature of arthritic knees. Arthritis Rheum 1994 Nov; 37(11):
1578-82[Medline].
Travell JG, Simons DG: Apropos Of All Muscles. Myofascial Pain and Dysfunction.
In: The Trigger Point Manual, The Upper Extremities. Vol 1. Baltimore, MD:
Williams & Wilkins 1983:45-102.
These work great for both Hot and Cold Pain Relief and a quick start to
healing
Buddy
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The Comfort Pac
Removable 7"x15" |
Herbal Buddy |
Herbal
Heating Pad Large |
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Contains the same soothing herbs as the Comfort Pac in a larger size with a removable
cover. $17.99 |
The herbal buddy is the most versatile hot
and cold pack available *the pack is 17"x 4 1/2" 27" overall
$14.99 |
Herbal Heating Pad 12"x14" great as a back heating pad in bed. It will stay warm
though the night. $24.99 |
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The Comfort Pac
Removable 7"x15" |
Herbal Buddy |
Herbal
Heating Pad Large |
|
Contains the same soothing herbs as the Comfort Pac in a larger size with a removable
cover. $17.99 |
The herbal buddy is the most versatile hot
and cold pack available *the pack is 17"x 4 1/2" 27" overall
$14.99 |
Herbal Heating Pad 12"x14" great as a back heating pad in bed. It will stay warm
though the night. $24.99 |
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When not to use a heating pad
Local application of heat is not advised in patients with decreased sensation
or circulatory impairment. It is also contraindicated over areas of malignancy
and not advisable in acute injury. Generally cold therapy is preferred in an
recent injury. Keep one of our packs in the freezer for cold therapy. Some
conditions respond best to an alternating treatment of cold therapy and a
heating pad. Usual application is about 20 minutes, not more than 30
minutes.
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