Module 2 - 5 Application of Cyrotherapy and Thermotherapy

Author: Mikaela Boham

The Clinical Application of Cryotherapy and Thermotherapy: Chapter 6 Therapeutic Modalities by Chad Starkey. The content in this lecture corresponds to Chapter 11, 12, and 13 in the Therapeutic Modalities: The Art and Science by Kenneth Knight and David Draper. Ice packs or cold packs include plastic bags filled with crush, chipped, or flaked ice, reusable cold gel packs consisting of a silicon base and an antifreeze gel, cold compression therapy units, which are using cold water to provide cold and compression, and instant cold packs which use a chemical reaction to produce cold. Ice packs or cold packs are good to use when someone has an acute injury. We can also use them to help prevent edema, and they're convenient when our athlete or patient needs to go. Indications for the use of cryotherapy include swelling, soreness, pain, inflammation, muscle spasms, neuralgia, and central nervous system spasticity. Contraindications for the use of cryotherapy include open wounds, circulatory insufficiency, anesthetized skin, deep vein thrombosis or DVTs, cardiovascular disease, allergies to cold or sensitivity to cold.

For precautions, we need to be careful on the perineal or ulnar nerves as they're very superficial. Avoid the face, eyes, and other sensitive areas and be careful around anesthetized skin. The treatment duration depends on the treatment goal, target tissue, and the amount of subcutaneous adipose tissue. Typical treatments are approximately 20 to 30 minutes long depending on the body part. There are different modes of treatment, which include ice bags, frozen peas, which are just as effective as other resources, reusable gel cold packs, instant cold packs, as well as other resources. Ice has a temperature of around 32° Fahrenheit, and therefore the risk of getting frostbite or chemical burns is minimized with the use of crushed ice or a nice bag. The temperature of the body will melt the ice and will result in a heat pocket, which protects the body. We need to be very cautious with reusable chemical packs.

It has been documented that these cold packs can get as cold as 12° Fahrenheit, and therefore is much colder than ice. The body does not always recognize this cold as being colder than ice. These treatments should have a barrier between the patient and the ice pack to reduce the incident of chemical burns. We also have to be concerned about reusable cold packs leaking, and thus creating other mechanisms for chemical burns if the material seeps into the skin. Same thing with instant cold packs; we have to worry about the chemical reaction as these chemicals could burn the skin and cause other issues. There are several considerations for the use of ice packs and cold packs including the number of treatments per day, will there be enough time for tissue rewarming in between treatments, and patients can have treatments no less than two hours apart. Oftentimes, ice packs or cold packs are combined with compression and elevation to enhance the treatment.

Again, reusable cold gel packs should not contact the skin. There's a potential that the body weight could puncture the reusable pack and may cause it to leak. In addition, patients sometimes have a difficult time moving if they're in pain, and therefore if the pack starts leaking, and injured patient may not be able to move quickly enough to remove the leaking ice pack. As far as insulation is concerned in the case of an icepack, applying an ice pack over a damp towel is the most effective form of treatment.

Module 2 - 5 Application of Cyrotherapy and Thermotherapy

The towel provides a barrier between the pack and the skin, and the wetness creates a better conduction for the transfer of coolant to the tissue. Again, this is needed only for reusable cold gel packs only. The treatment that is most associated with frostbite is either a reusable cold pack or chemical pack, as both of these options could get colder than freezing, and may result in chemical burns and frostbitten tissue. The comfort level of the patient is very important, but remember that we have to go through the four sensations of cold to reach numbness.

Remember CBAN? Cold Burning Aching Numbness? You need to make sure that you're reaching numbness, which will take at least 20 to 30 minutes of treatment. Skin temperature is not a good indicator of the effectiveness of cryotherapy treatment programs. Remember that the skin is the first structure to cool, but the target tissue is located most the time much deeper than the superficial structure of the skin.

The skin is not an accurate predictor of intramuscular temperature. The best way to measure intramuscular temperature is to place a thermometer within the muscle itself. Placing a thermometer within the muscle is not very practical for everyday clinical use, but this is why we use evidence-based medicine and base our protocols off of other research so that we can figure out what is best for our patients. There have been some studies examining the differences between cubed, crushed, and wetted ice. One great study was done by Dykstra and colleagues in 2009. The hypothesis of the study was that the wetted ice would be the coldest, followed by the crushed, and then the cubed.

Here are the results of this study. These graphs demonstrate that the wetted ice was indeed the coldest, but the cubed ice was second and then finally the crushed ice over a period of 20 minutes. Patients were then followed for a 100 minutes to document tissue rewarming. An additional study examined the different types of compression resulting in decreased intramuscular temperature.

The study by Tomchuk and colleagues published in 2010 and it examines the use of flexi rap, elastic wrap, and no compression on inter muscular temperature of patients. Each patient was subjected to three treatments randomly while intramuscular temperature was taken at the gastrocnemius muscle. The study demonstrated the patient saw the greatest temperature change in the elastic rap compression group, followed by flexi wrap, and then none. The difference between the elastic wrap and flex-i rap are not massively different compared to the no compression group. From these results, if the use of an elastic rap is available it is the best treatment, however many clinicians know that if an elastic wrap is issued to patient, it will typically go home with the patient and then will not come back with them on their next visit, thus making elastic wraps and impractical and costly compression option for many patients. Flexi wrap on the other hand, uses single-use disposable and is cheap, but also results in significant decreases in tissue temperature as a compression device; therefore, it remains the compression option of many clinicians, especially if they're leaving the clinic for treatment. Cold compression units are the combination of chilled water to provide cold and compression simultaneously. Cold compression therapy units are good to use with active inflammation, acute injury, pain, or chronic pain.

Indications include swelling, acute injury, chronic injury, and edema. Contraindications include open wounds, circulatory insufficiency, anesthetized skin, deep vein thrombosis or DVT, cardiovascular disease, allergies and sensitivities to cold. In addition, body type or fat distribution may also be a contraindication depending on the target tissue. Precautions: we need to evaluate blood pressure; we also need to evaluate for circulatory insufficiency. The duration of the treatment is typically 20 to 30 minutes. There are many different types of cold compression units including CryoCuff, GameReady, and the BioCryo, in addition to others on the market.

Cold compression units are good for treating large areas of edema, especially those associated with acute injury or postoperatively. Considerations for the use of cold compression units include taking the patient's blood pressure. The diastolic blood pressure must be evaluated for the BioCryo unit. We also need to be aware of unstable fractures and compartment syndrome as any increase in pressure for these two injuries is contraindicated. Cold compression units are frequently combined with elevation to enhance the effects of treatment. The CryoCuff is a low-tech version of the cold compression unit. This unit costs approximately a $125-150.

The way the CryoCuff works is by placing four liters of ice and water within the thermos. The thermoses been elevated and the cooler fills and pressurizes the cuff. The compression is controlled by gravity and is proportional to the elevation of the cooler; for example if the cooler is 20 inches above the cuff during filling, the applied compression will be approximately 35 millimeters of mercury. When the body heat warms the water within the compression device, it is re-chilled simply by lowering the thermos. The one drawback of this unit is that the water does not circulate on its own, and it requires someone to elevate and lower the thermos to change the water within the compression unit. The GameReady has become increasingly popular, but is much more expensive than the CryoCuff.

The GameReady machine cost approximately $2000 for the machine itself, and then each additional part cost about a $1000 each. The GameReady machine allows for a motorized circulation of ice water through a compression device. The GameReady machine runs by plugging it in an AC electrical unit into the wall.

The game ready does not require much work on the clinician and will maintain a specific temperature for the entire duration of the treatment. The BioCryo is a little bit older form of a cold compression unit. This unit requires that the extremity devices be kept in a freezer. A stockinette or a barrier must be provided in between the skin and the extremity device when applied to a patient.

Once the extremity compression units are properly cooled, they can be applied to the patient. This unit uses a gradient is sequential in its device. There are four chambers on a lake or the arm which compresses the body parts sequentially.

Before the treatment, you must take the patient's blood pressure. The pressure setting for the unit should not exceed the diastolic blood pressure of the patient. Once setting the unit for the upper extremity, the pressure should be less than 50 millimeters of mercury.

This machine is fairly costly, the machine cost approximately $1600 for the machine and comes with several attachments including one arm, one arm and shoulder, one half leg, and one full leg. Remember, all attachments must be kept in a freezer as well, which makes this cold compression unit impractical for traveling, as access two freezers isn't usually readily available. In addition, the repetitive use with many patients requires multiple sleeves, and may require the purchase of more than one unit. Ice massage is when water is frozen in a paper cup, and then is massage over a small area of skin. Ice massage is good to use with shin splints, specific points of pain or spasm, and applying cold with pressure for example for a deeper and quicker treatment or four trigger point therapy.

Indications include swelling or specific areas of pain. Contraindications include open wounds, fractures, circulatory insufficiency, anesthetized skin, DVT, cardiovascular disease, allergies, or sensitivities to cold. As a precaution, we can use am ice cup massage possibly with someone with anesthetized skin because the cooling is not nearly as intense as using an ice bag or an ice pack.

Ice cup massage works well on small areas, typically good for spasms, contusions, or shin splints. It is not a good treatment for acute springs, especially for ligamentous damage, but can be effective for acute strains, such as tendon or muscle damage. Typical treatment duration is somewhere between 5-15 minutes or until the tissue reaches numbness.

Several contraptions have been created for ice cup massages. The picture on the left has a plastic handle that fits into a cup, which gets filled with water. When the lower cup is separated, the plastic handle keeps the clinicians hand from being cooled, which makes it more comfortable for the clinician. The picture on the right is another cryo-massage tool.

The water is frozen in a push pop-type container and then the ice cup is then allowed to be pushed up as the ice gets used in much the same manner as a push pop ice cream container. Cryostretch is the use of Vapocoolant sprays--a liquid that quickly evaporates and cools the skin. It is applied to the skin, while the underlying muscles in fascia are simultaneously stretched. Cryostretch is used for treating trigger points, local muscle spasm, and other myofascial conditions. Contraindications include open wounds, circulatory insufficiency, anesthetized skin, DVT, cardiovascular disease, allergies, sensitivity to cold, body types (also fat distribution), possible allergy to the vapocoolant, and possibly acute inflammation.

A vapocoolant spray may also be flammable, which we'll talk about in a minute. Precautions include the flammability of the vapocoolant, possibility of frostbite and possible allergic reaction to the chemical. The spray and stretch technique includes being 12 inches away from the tissue and spraying the entire muscle length in a sweeping manner.

The sweeping only occurs in one direction: this treatment is good for trigger points, local muscle spasm, but there are several contraindications. There is a potential for frostbite of the patient if you spray too close to the skin. The Vapocoolant may also be flammable, so be careful when using this treatment if you're on a sideline close to heaters or if the patient is a smoker. The risk of flame is increased of the vapocooling spray includes the chemical ethyl chloride. In addition, the patient may be allergic to the spray. If you use this close to the face and eyes, make sure to protect those vital structures. Also, because of the potential of inhaling the spray, have the patient turn their head away or you could block the spray from going in the face.

If the fumes are inhaled, ethyl chloride can become a general anesthetic, so be careful of the patient’s potential to pass out or appear loopy after the vapor coolant is inhaled. There are some questions as to the effectiveness of this treatment. The vapocoolant does not actually change the tissue temperature like other cryotherapy modalities; therefore, the spray and stretch technique may not be as effective as if other cryotherapy modalities are utilized. An ice immersion is a tub or bucket that is filled with ice and water, and is used for cooling large and/or irregularly shaped areas.

The body part is usually the foot or the ankle or the elbow, wrist, or hand. It becomes immersed in the solution. Ice immersion is the most uncomfortable of all cold treatments.

Ice immersion including cold whirlpools is good to use with large areas, muscle soreness, or bony areas. Indications include swelling, acute injury, especially those of irregularly-shaped distal body parts. Contraindications include infection, open wounds, circulatory insufficiency, anesthetized skin, DVT, cardiovascular disease, allergy to cold, sensitivity to cold, and body type or fat distribution. Precautions: we need to be concerned of pitting edema, lotion, or stuff on the body, knowing the time limits and looking for an anesthetized skin. The treatment duration of ice immersion is typically 10 to 15 minutes. The temperature of the ice immersion is usually 50-60° Fahrenheit. For smaller body parts, the temperature should be closer to 50° Fahrenheit and approximately 10 minutes of treatment. For larger body parts, the temperature should be a little warmer, approximately 60°Fahrenheit and maybe a little bit longer treatment, about 15 minutes.

Sometimes barriers are used to make the treatment more comfortable including toe sleeves, as this is the most common complaint of individuals who participate in ice immersion. A cold whirlpool treatment combines ice immersion with the massaging effects of jets, the buoyancy effect from the water submersion, and the increase in hydrostatic pressure from the pressure that the water exerts on the body part. The use, indications, and contraindications are the same as cold immersion mentioned on the previous slide. The treatment duration for the cold whirlpool is approximately 10 to 30 minutes based on the amount of the body that is submerged.

The more the body that is submerged, the warmer the water should be for the patient. The optimal treatment temperature is between 50 and 65° Fahrenheit. For small body parts, the temperature should be closer to 50° Fahrenheit and approximately 10 minutes of treatment.

For larger body parts, the temperature should be closer to 65° Fahrenheit and approximately 30 minutes of treatment. Barriers such as toe sleeves can also be used for comfort. Considerations for cold whirlpool use should include the examination the skin for infection or open wounds, as the world pool must be disinfected between each treatment and/or patient. This is a substantial time and resource dedication. The treatment of cold whirlpool is often combined with stretch and exercise.

Common exercises include ankle ABC's, circles, and ankle pumps. There is some research that is documented the effect of preventive cold whirlpool use on post exercise to help prevent or decrease the effects of delayed onset muscle soreness or DOMS post exercise. Cold whirlpool treatments are very common post-exercise among collegiate and professional athletes.

The picture on the right is of the Major League Baseball Chicago White Sox hydrotherapy area. Many teams have dedicated significant resources to cryotherapy rooms. The use of water therapy is not unique to sports. There are several factors that make aquatic therapy effective for many patients. Buoyancy is the lifting force that is provided by the water. Many elderly patients find aqua therapy decreases the pressure on aching joints making it easier to move and exercise. In addition, in a non-weight bearing patient, aquatic therapy can help the patient regain a normal gait because the buoyancy effects allow the patient to exercise without the full effects of their body weight.

Hydrostatic pressure is a force that is exerted on the body part that is immersed in a non-moving fluid. Hydrostatic pressure creates a pressure gradient which can help force fluids and a distal extremity to move proximally. Many people feel thinner in a pool of water due to this hydrostatic pressure creating a force on the body.

Resistance is created against movement in the water if used for rehabilitation purposes. It can create a massaging effect if used for treatments. The water creates a resistance which is an excellent form of therapy; under water running, or other exercises are frequently used during rehabilitation protocols. Cold whirlpool treatments are great for irregularly shaped body surfaces, typically distal body segments. It combines the effects of cryotherapy with the effects of aquatic therapy such as buoyancy, hydrostatic pressure, and the massaging effects of resistance. Safety is the most important thing; no patient should ever turn on a whirlpool while they are actually in the whirlpool. All whirlpools should be plugged into a ground fault circuit interrupter or a GFCI. All GFCI should be at least three feet off the ground in the event of water.

A ground fault circuit interrupter is designed to protect the patient from electrical shock by interrupting a circuit when there is a difference in the currents in the hot and neutral wires. If there is a discrepancy of more than 5 milliamperes, current leakage has been detected and the GFCI will stop the flow of electricity. Ground fault circuit interrupters must be distinguished from standard circuit breakers. Although GFCI stop the current flow at a very low amperage, standard circuit breakers require much larger discrepancy up to 25 amps to be activated. Circuit breakers are not adequate for the use in athletic training facilities, physical therapy clinics, or hospitals, especially in hydrotherapy areas.

In 1991, the National Electrical Code require the use of GFCIs in all healthcare facilities that use therapeutic pools. GFCIs are easily recognized by their “tests” and “reset” buttons. If the GFCI trips, disconnect the patient from the unit, turn the power off to the unit, check all connections, depress the reset button on the GFCI, and restart the equipment without the patient being in contact with the unit; ensure that the ground fault trip does not occur again. If the GFCI trips again, disconnect the unit, label the unit and outlet as ‘out of order’ and call for service. Cryo-kinetics is the combination of ice and active exercise.

Cryo-kinetics is good to use with acute injuries, inflammatory conditions, acute pain, and when we want to push out swelling. It is good for sprains, but not strains. Indications include swelling, acute injury, chronic injury, edema and ligamentous injury. Contraindications: it does not allow patients to fill pain, so tissue could be damaged during exercise.

We don't use this with open wounds, circulatory insufficiency, anesthetized skin, DVT, cardiovascular disease, allergy to cold, sensitivity to cold, or body type fat distributions that prohibit the target tissue from being cooled properly. Precautions: there is a possibility that the active exercise may increase the tissue damage if we go too far. We also have to be concerned about any circulation insufficiency that the patient may have. The treatment duration of the cryotherapy treatment is typically ice for 10-15 minutes or until numbness, followed by active exercise until the tissue starts rewarming. This ice and exercise process will be repeated approximately five times. The mode of the cryo-kinetics includes the use of cold whirlpools, ice immersion, ice massage, and an ice pack.

Barriers such as toast leaves can be used for patient comfort during the cryo treatment. Cryo-kinetics are most commonly used for ligamentous injury. The most common application of cryo kinetics is seen with ankle sprains, most typically, lateral ankle sprains. It is good to use cryo-kinetics when range of motion or strength is limited due to pain. Cryo-kinetics is not good for muscle strains as active early exercise could damage the healing muscle. If pain is felt while the patient is still numb, then there's too much stress that is being applied to the tissue, and we need to back off the treatment. Remember that the exercise maybe simple, such as ankle pumps, toe raises, heel raise,s or even simple standing or balance activities. Pain is always our guide to any rehabilitation protocol, but especially during cry- kinetics.

Moist hot packs or moist heat packs are silica filled packs that are stored in hot water between uses. The packs are removed from heating, wrapped in a terry cloth cover towel, and used to deliver moist heat to the body. The resulting temperature increase is localized to superficial tissues. Moist hot packs are good use when we have subacute or chronic inflammation, subacute or chronic pain. Indications include acute or chronic inflammation, subacute or chronic pain, subacute or chronic muscle spasms, decreased range of motion, hematoma resolution, increase muscle tendon or fascia elasticity, reduction in joint contractures. Contraindications include acute injuries, peripheral vascular disease, impaired circulation, and poor thermal regulation.

We need to take precaution that there is no direct contact with the skin. We do not lay on hot packs. If the hot packs are changed during treatment, make sure to prevent burns. Traditional hot packs cost approximately $200 for 12 packs and 12 terry cloth covers that are another $270. In addition, a clinician we need to purchase a hydrocollator with which to house these moist heat packs, which can cost anywhere from $500 -2,000.

A typical treatment duration for moist hot packs is 15 to 30 minutes. The temperature of the hot pack for optimal treatment is 160-166° Fahrenheit. The mode of treatment is from silica filled packs. The barrier between the patient and the moist hot pack requires four to six layers. There should never be any direct contact of the moist hot pack with the patient's skin.

The one important consideration of moist heat packs is that compression increases the effectiveness of this modality, so it's best not to lay on them. If it is unavoidable for a patient to lay on the moist heat pack, you need to place additional layers for the patient. The heat can become a lot more concentrated if the patient is laying on the hot pack, and someone who is in pain may not want to move very quickly if the heat pack begins to burn the patient. The clinician should always be ready with additional layers of towels if the moist heat pad gets too hot. The effects of the moist heat pack are extremely superficial; therefore, the treatment does not really heat the muscle, so if the target tissue is deep, such as muscle, then this treatment is ineffective.

Sometimes moist heat packs are combined with stretching or warm-up exercises to help facilitate the movement of the muscles, which results in heating of the deeper tissue. A warm whirlpool treatment combines heat immersion with the massaging effects of jets, the buoyancy effects of warm water submersion, and the increase in hydrostatic pressure from the pressure that the water exerts on the body. Warm whirlpool use is good for subacute pain, decreased range of motion, and generalized pain or decreased muscle spasms.

Contraindications include acute injuries, or any limb that's in a gravity dependent position, fever, patients requiring postural support during treatment, skin conditions, for spotlight tubs, they must be clean between use, and general heat contraindications. Precaution should include that the whirlpool will be connected to a ground fault circuit interrupter. We need to instruct the patient not to turn on the whirlpool motor while in the water. The switch should be out of the patients reach. Patients in the whirlpool should be in view of the staff at all times. Combination of increased circulation and placement of the extremity in a gravity dependent position tends to increase edema.

The motion of the flowing water may also nauseate some patients; they actually become motion sick. Patients under the influence of drugs are at risk of losing consciousness during treatment. Full-body immersion may also impair breathing and lead to respiratory distress. The treatment duration should be between 10 and 30 minutes. The mode is a whirlpool with the turbine. The temperature of the warm whirlpool treatment should be between 90 and 110° Fahrenheit.

Small body parts should be kept at a temperature of closer 110° Fahrenheit for a treatment time of 10 minutes. Larger body parts should be kept a temperature closer to 90° Fahrenheit for a treatment time of approximately 30 minutes. Barriers are typically not needed for warm whirlpool treatments.

The biggest consideration for the use of warm whirlpools is infection and open wounds. The use of warm whirlpool is frequently combined with stretch and exercise. Warm moral pool treatments are great for irregular body surfaces, typically distal body segments. It combines the effects of thermotherapy with the effects of aquatic therapy such as buoyancy, hydrostatic pressure, and then massaging effects of resistance. Just like cold whirlpool use, safety is the most important thing. No patient should ever turn on the whirlpool while they are in the whirlpool.

All whirlpools should be plugged into a ground fault circuit interrupter. A paraffin bath is a mixture of wax and mineral oil that is melted into a unit. The low specific heat of the mixture allows warm temperatures to be used during treatment. Paraffin is used to deliver heat to small, irregularly-shaped areas especially when range-of-motion exercises are not part of the treatment. This can be used for the treatment of chronic inflammatory conditions and softening of the skin. Contraindications include uncovered open wounds, sensory loss, peripheral vascular disease, cancerous lesions, and skin infections. As a precaution, do not touch paraffin tanks on the side or the bottom. The sensation of paraffin is misleading as to the actual temperature of the treatment.

Avoid treatment with anyone required to catch or throw a ball or any worker who is required to maintain a good grip post-treatment. The mineral oil in the wax causes the hands to become very slippery post treatment. The treatment duration of paraffin bath includes removing any jewelry, thoroughly washing of the body part including scrubbing underneath the nails, spreading the fingers and toes and keeping them steady, immersing the body part and removing it allowing the wax to dry. This process should be repeated 6-12 times until the wax becomes a thick glove around the body part.

Once the body part is waxed, wrap it in a plastic bag and a towel for approximately 15-20 minutes. After the treatment, peel off the wax and you should throw the wax in the trash. If you place the wax back into the paraffin bath, you are not only placing the wax back into the bath, but also any associated dead skin cells, and any naturally occurring bacteria from the skin, as well as many other things. Any bacteria which makes its way into the paraffin bath has a perfect breeding ground as the bath is moist, hot, and dark. The treatment temperature is between a 118-126° Fahrenheit, which is a low specific heat. Paraffin treatment is often combined with range of motion exercises or joint mobilization after treatment.

Paraffin baths aren't overly expensive; there approximately $200 for the bath and cost about $32 to refill three pounds of paraffin. Fluidotherapy is when ground cellulose is heated and then circulated by air to deliver dry heat to an extremity. Fluidotherapy is used for superficial heating of the extremities, especially the wrist, hand, and fingers, and possibly the ankle and toes, although the application of the lower extremity is a lot more difficult based on the modalities’ height. Fluidotherapy is good to use when there is a decrease in the range of motion for non-rheumatic arthritis or localized pain.

Contraindications include open uncovered wounds, sensory loss, peripheral vascular disease, cancerous lesions, and general medical conditions that reduce the patience tolerance to heat. As a precaution, cover open wounds prior to treatment. Patients that are sensitive to allergic reactions caused by dust and pollen should be monitored during treatment. The treatment duration should be approximately 20 minutes. The mode of transmission is that the warm air is working via convection at a temperature of 110-125° Fahrenheit. It is common to combine fluidotherapy with range-of-motion exercises and mobilizations.

Fluidotherapy machines are fairly expensive; a typical fluido machine cost between $4,000-6,000. The limited application and potential to be extremely messy prevents many clinicians from purchasing fluidotherapy units, unless it is for a specific hand therapy clinic. A contrast bath consists of alternating amounts of heat and cold using hot and cold whirlpool, hot and cold immersion, or moist heat packs and cold packs. Contrast therapy is used for the transition between cold and heat modalities, but there is no evidence to support this, which means that the efficacy of this treatment has not been fully established. Contraindications for the use of contrast bath include acute injuries, hyper sensitivity to cold, contraindications to whirlpool, use or cold use or heat applications. Precautions include whirlpool precautions, neoprene toe caps may be used to decrease discomfort associated with cold immersions, combination of increased circulation, and placement of the extremity in a gravity dependent position tends to increase edema. The theory of contrast therapy is that the tissue is subjected to cycles of vasoconstriction and vasodilation.

This is proposed to stimulate the peripheral blood flow and create a pumping action, which should, in theory, Aids Venus and lymphatic return. The treatment duration is approximately 20 to 25 minutes, the mode of the modality transmission is 3-4 minutes of warm immersion at only a temperature of approximately a 105° Fahrenheit, followed by one minute of cold immersion at a temperature of approximately 50° Fahrenheit. The most commonly used ratios are 3:1 or 4:1 for hot and cold applications. The last stage of the contrast therapy should end either after heat or cold depending on the stage of the injury and the patient's activity plans after the treatment. The evidence suggests that contrast baths do not create numbness, but can increase local pain. It does not result in an alternating vasodilation and construction, as has been previously theorized. It does not affect muscle temperature due to the time of the treatment. It is unable to produce a significant difference in muscle temperature at one centimeter deep.

Topical pain killers or analgesics are sprayed on or rubbed into the skin over painful muscles or joints. Although all are designed to relieve pain, different products use different ingredients. Some topical heat creams have also been thrown into superficial therapy treatments. Examples of topical heat creams include Biofreeze, Icy Hot, Thera-Gesic, Cramergesic, Tiger Balm, and many, many others. Research has indicated that there is a decrease in skin temperature of less than 1° Fahrenheit with the use of topical heat creams. Here are the most common ingredients found in the products available without a prescription. Topical heat creams are counterirritant ingredients such as methanol, methyl salicylate, and camphor oil, that are called counterirritant because they created burning or cooling sensation that distracts your mind from the pain.

Salicylate is the same ingredient that give aspirins its pain relieving quality are found in some creams. When they're absorbed into the skin, they may help with pain, particularly in joints close to the skin such as the fingers, knees, and the elbow. Capsaicin is a main ingredient of hot chili peppers. Capsaicin is one of the most effective ingredients for topical pain relief. When first applied, capsaicin creams cause a warm tingling or burning sensation. This gets better over time; you may need to apply these creams for a few days to a couple of weeks before you notice relief from pain. Here's what you need to know about getting the greatest effects and minimizing the risks of these products.

Read the package insert and follow the directions carefully; if there is an insert, save it and refer to it later. Never apply these creams to wounds or damaged skin. Do not use them in association with heating pads because it could cause burns. Do not use under a tight bandage. Wash your hands well after using them; avoid touching the eyes with the product on your hands. If you are allergic to aspirin or are taking blood thinners, please check with your doctor before using any topical medication that contains salicylates. Some cooling modalities that have gained popularity recently. These include whole-body cryotherapy units, cold chambers, and air cooling.

Attendance of annual meetings and symposiums is a great place to check out new resources. This is a booth with a new proposed product: this is a Cryo Helmet. The guy at the booth graciously modeled the helmet for us.

This unit has been marketed as a new concussion treatment with the theory the early application of ice or cryotherapy could help decrease the effects of concussion in much the same way as it does for acute injury. There's no research at this point in time that state's the use of this Cryo helmet has any effect on concussions, but it's being marketed as such a product. Quiz number five will be available on blackboard. It will cover chapter 6 and 14 in the Starkey Textbook. The quiz will be worth 10 points and you will have 10 minutes to complete the quiz. Exam 2 will be over Superficial Cryo and Thermotherapy. It will be on blackboard; there will be approximately 40 multiple choice, true/false, fill-in-the-blank, multiple answers, and ordering questions, which are worth about 80 points. There's also some essay questions; selecting the wrong answers will result in a deduction of points.

Lab and Exam review: we will meet for a cryotherapy and thermotherapy lab in the athletic training center; please look on blackboard for the associated dates. The review for exam 2 is available on blackboard. Please see your class for the associated material. On the lab day, we will meet an Island Hall Room 179 which is the location of the athletic training center.

Please bring a pen or pencil, and notes from class would be highly encouraged. Be on time as instructions will start at the beginning of class time, and labs will take you the entire time for class. The dress code will be strictly enforced: t-shirts are required.

All shirts must have sleeves: no tank tops, cut-offs, or any other variations will be allowed. Shorts (no jeans) and tennis shoes are required. The shorts must meet the fingertip rule: this means if you extend your fingertips down by the side of your leg, your shorts must not be shorter than your fingertips. I realize that some people have longer arms and legs than others, so similar style shorts may fit each person differently, but the rule needs to be applied to all. No hats are worn in the athletic training facility; this includes any style of hat. If you're not dressed properly as determined by the instructor, you will be sent home for the day.

If you are sent home, you'll receive an automatic zero for the lab. No makeup lab days will be offered, so please be on time, be prepared, and be an active learner. This is your chance to have some real-life hands-on learning opportunities.

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