INFRARED MODALITIES 245

LAB ACTIVITY
PATIENT POSITIONING
DESCRIPTION:

The positioning of a patient prior to the application of a and facilitates venous flow of blood. Proper positioning allows
physical agent modality is one of the most important aspects the use of optimal body mechanics by the therapist in the
contributing to a successful treatment. Placing the patient in application of the selected treatment.
an aligned and supported position insures muscular relaxation

THERAPEUTIC EFFECTS:
Muscular relaxation
Facilitated venous blood flow

PATIENT POSITIONING
PROCEDURE Evaluation
1 2 3
1. Check supplies.
a. Pillows
b. Towels
c. Sheets
2. Question patient.
a. Verify identity.
b. Verify treatment area.
3. Position patient.
a. Prone on table.
i. Place pillow under abdomen; lumbar spine should be flat.
ii. Place pillow under ankles.
iii. Insure proper body alignment.
iv. Drape patient to maintain modesty.
b. Supine.
i. Place pillow under head and knees.
ii. Insure proper body alignment.
iii. Drape patient to maintain modesty.
c. Sitting.
i. Seat patient on chair or stool leaning forward.
ii. Support head and shoulders with pillows.
iii. Rest forearms and hands on table.
iv. Insure proper body alignment.
v. Drape patient to maintain modesty.
4. Administer the treatment.
5. Complete the treatment.
6. Return equipment to storage after cleaning.
246 THERMAL MODALITIES

LAB ACTIVITY
ICE MASSAGE
DESCRIPTION:

Ice massage is performed by rubbing a small area of the body depressor for a handle, are sometimes used, but the tongue
with a block of ice until superficial anesthesia is achieved. The depressor may abrade the skin during the treatment. The
block of ice is produced by filling and then freezing a cup of ideal cup is a waxed paper cup; the wax provides some insula-
water at a temperature of no colder than ⫺5°C. Styrofoam tion to keep your hand warm, and half the cup can be torn
cups are often recommended, but the chunks of styrofoam away in a single piece. The bottom of the cup should be
that are removed from the cup during the treatment tend to removed, not the top. This permits the cup to act as a funnel,
be messy. Freezing water in empty juice cans, with a tongue and keeps the ice from slipping out of the cup.

PHYSIOLOGIC EFFECTS:
Vasoconstriction
Anesthesia
Decreased local metabolism
Decreased connective tissue elasticity

THERAPEUTIC EFFECTS:
Decreased or prevented swelling
Decreased pain
Decreased inflammation
Minimized secondary tissue damage

INDICATIONS:
The primary indication for ice massage is pain of musculoskeletal origin that is pre-
venting the effective use of therapeutic exercise; for example, an individual with
restricted ankle motion who is prevented from applying sufficient force to produce
remodeling of the connective tissue owing to pain. Ice massage will decrease the pain
enough to permit an effective stretch. However, care must be taken to avoid stressing
the connective tissue too much; the anesthesia provided by the ice may allow an overly
aggressive individual to produce a sprain or strain.
Ice massage is also useful to help prevent an increase in inflammation and swelling
of a joint following a therapeutic exercise session. It is probably no more effective than
an ice pack, but often provides a more profound anesthesia.

CONTRAINDICATIONS:
• Lack of normal temperature sensibility
• Cold hypersensitivity (urticaria or hemoglobinuria)
• Vasospastic disorders (e.g., Raynaud’s disease)
• Coronary artery disease
• Hypertension

ICE MASSAGE
PROCEDURE Evaluation
1 2 3
1. Check supplies.
a. Obtain towel to absorb water as it melts, ice cube, sheet or towels for
draping.
b. Check freezer for appropriate temperature.
INFRARED MODALITIES 247

PROCEDURE Evaluation
1 2 3
2. Question patient.
a. Verify identity of patient (if not already verified).
b. Verify the absence of contraindications.
c. Ask about previous cryotherapy treatments, check treatment notes.
3. Position patient.
a. Place patient in a well-supported, comfortable position.
b. Expose body part to be treated.
c. Drape patient to preserve patient’s modesty, protect clothing, but allow
access to body part.
4. Inspect body part to be treated.
a. Check light touch perception.
b. Check circulatory status (pulses, capillary refill).
c. Verify that there are no open wounds or rashes.
d. Assess function of body part (e.g., ROM, irritability).
5. Apply ice massage.
a. Expose block of ice.
b. Rub ice on hand to smooth rough edges.
c. Warn the patient that you are going to put your cold hand on the body
part to be treated, then do so.
d. Remove your hand after 2 or 3 seconds, and warn the patient that you are
going to put the ice on the body part to be treated, then do so.
e. Begin rubbing the ice block in a circular motion on the body part being
treated. Do not put additional pressure on the ice. Move the ice at about 5
to 7 cm per second. Do not let melted water run onto areas of the body
that are not being treated.
f. Check the patient’s response verbally about every 2 minutes. Perform a
visual check of the area continuously during the treatment. If wheals or
welts appear, or if the skin color changes to absolute white within the first
4 minutes of treatment, stop the treatment. Remind the patient to tell you
when the area is numb.
6. Complete the treatment.
a. When the patient tells you the area is numb, remove the ice and dry the
area. Perform a test for light touch sensation to verify anesthesia.
b. Remove material used for draping, assist the patient in dressing as needed.
Place the unused ice in a sink, and the cup in the trash.
c. Have the patient perform appropriate therapeutic exercise as indicated.
d. Clean the treatment area and equipment according to normal protocol.
7. Assess treatment efficacy.
a. Ask the patient how the treated area feels.
b. Visually inspect the treated area for any adverse reactions (e.g., wheals,
welts).
c. Perform functional tests as indicated.
248 THERMAL MODALITIES

LAB ACTIVITY
COLD PACKS
DESCRIPTION:

Commercially available cold packs are usually a vinyl cover are available in various sizes, including one designed to encir-
filled with a gel that does not solidify at low temperatures. cle the cervical region. The packs are generally wrapped in
Cooling units designed specifically for the cold packs are a wet towel to increase the thermal conductivity from the
available, but they may be kept in a household-type freezer. patient.
The temperature of the freezer should be 0 to ⫺5°C. Packs

PHYSIOLOGIC EFFECTS:
Vasoconstriction
Superficial anesthesia
Decreased local metabolism
Decreased connective tissue elasticity

THERAPEUTIC EFFECTS:
Decreased or prevented swelling
Decreased pain
Decreased inflammation
Decreased secondary tissue damage

INDICATIONS:
The primary indication for the use of a cold pack is in the acute phase of a soft tissue
injury. The cooling of the injured area will help prevent the development of swelling
and may assist in the resolution of swelling by altering the Starling-Landis forces at the
capillary bed.
A cold pack is also useful to minimize or prevent increased inflammation or pain
following a session of therapeutic exercise. The depth of anesthesia achieved with a cold
pack is generally considerably less than with an ice massage.

CONTRAINDICATIONS:
• Lack of normal temperature sensibility
• Cold hypersensitivity (urticaria or hemoglobinuria)
• Vasospastic disorders (e.g., Raynaud’s disease)
• Coronary artery disease
• Hypertension

COLD PACKS
PROCEDURE Evaluation
1 2 3
1. Check supplies.
a. Obtain wet towel to wrap cold pack in, cold pack, sheet or towels for
draping.
b. Check freezer for appropriate temperature.
INFRARED MODALITIES 249

PROCEDURE Evaluation
1 2 3
2. Question patient.
a. Verify identity of patient (if not already verified).
b. Verify the absence of contraindications.
c. Ask about previous cryotherapy treatments and check treatment notes.
3. Position patient.
a. Place patient in a well-supported, comfortable position.
b. Expose body part to be treated.
c. Drape patient to preserve patient’s modesty, protect clothing, but allow
access to body part.
4. Inspect body part to be treated.
a. Check light touch perception.
b. Check circulatory status (pulses, capillary refill).
c. Verify that there are no open wounds or rashes.
d. Assess function of body part (e.g., ROM, irritability).
5. Apply cold pack.
a. Wrap cold pack in wet towel.
b. Warn the patient that you are going to put the cold pack on the body part
to be treated, then do so.
c. Set a timer for the appropriate treatment time (generally about 20 min-
utes), and give the patient a signaling device. Make sure the patient under-
stands how to use the signaling device.
d. Check the patient’s response verbally after the first 2 minutes, then about
every 5 minutes. Perform a visual check of the area if the patient reports
any unusual sensation. If wheals or welts appear, or if the skin color
changes to absolute white within the first 4 minutes of treatment, stop the
treatment.
6. Complete the treatment.
a. When the treatment time is over, remove the cold pack and dry the area
with a towel.
b. Remove material used for draping, assist the patient in dressing as needed.
c. Have the patient perform appropriate therapeutic exercise or apply tape or
compression wrap as indicated.
d. Clean the treatment area and equipment according to normal protocol.
7. Assess treatment efficacy.
a. Ask the patient how the treated area feels.
b. Visually inspect the treated area for any adverse reactions (e.g., wheals,
welts).
c. Perform functional tests as indicated.
250 THERMAL MODALITIES

LAB ACTIVITY
ICE PACKS
DESCRIPTION:

An ice pack uses crushed ice at a temperature of 0 to ⫺5°C. energy from the patient. A major advantage of an ice pack
The ice may be placed in a plastic bag and wrapped in a wet over a cold pack is that the ice pack can be almost any size
towel or may be placed directly in a wet towel. The use of a and shape; therefore, an ice pack is useful for treating any
plastic bag will minimize the potential mess from water drip- body part.
ping, but it may also decrease the conduction of thermal

PHYSIOLOGIC EFFECTS:
Vasoconstriction
Superficial anesthesia
Decreased local metabolism
Decreased connective tissue elasticity

THERAPEUTIC EFFECTS:
Decreased or prevented swelling
Decreased pain
Decreased inflammation
Decreased secondary tissue damage

INDICATIONS:
The primary indication for the use of an ice pack is in the acute phase of a soft tissue
injury. The cooling of the injured area will help prevent the development of swelling
and may assist in the resolution of swelling by altering the Starling-Landis forces at the
capillary bed.
An ice pack is also useful to minimize or prevent increased inflammation or pain
following a session of therapeutic exercise. The depth of anesthesia achieved with an ice
pack is generally considerably less than with an ice massage.

CONTRAINDICATIONS:
• Lack of normal temperature sensibility
• Cold hypersensitivity (urticaria or hemoglobinuria)
• Vasospastic disorders (e.g., Raynaud’s disease)
• Coronary artery disease
• Hypertension

ICE PACKS
PROCEDURE Evaluation
1 2 3
1. Check supplies.
a. Obtain wet towel to wrap ice in, an appropriate amount of crushed ice,
sheet, or towels for draping.
b. Check freezer for appropriate temperature.
2. Question patient.
a. Verify identity of patient (if not already verified).
b. Verify the absence of contraindications.
c. Ask about previous cryotherapy treatments, check treatment notes.
INFRARED MODALITIES 251

PROCEDURE Evaluation
1 2 3
3. Position patient.
a. Place patient in a well-supported, comfortable position.
b. Expose body part to be treated.
c. Drape patient to preserve patient’s modesty, protect clothing, but allow
access to body part.
4. Inspect body part to be treated.
a. Check light touch perception.
b. Check circulatory status (pulses, capillary refill).
c. Verify that there are no open wounds or rashes.
d. Assess function of body part (e.g., ROM, irritability).
5. Apply ice pack.
a. Warn the patient that you are going to put the ice pack on the body part
to be treated, then do so. Make sure the draping will catch any water that
melts from the ice pack.
b. Set a timer for the appropriate treatment time (generally about 20 min-
utes), and give the patient a signaling device. Make sure the patient under-
stands how to use the signaling device.
c. Check the patient’s response verbally after the first 2 minutes, then about
every 5 minutes. Perform a visual check of the area if the patient reports
any unusual sensation. If wheals or welts appear, or if the skin color
changes to absolute white within the first 4 minutes of treatment, stop the
treatment.
6. Complete the treatment.
a. When the treatment time is over, remove the ice pack and dry the area
with a towel.
b. Remove material used for draping, assist the patient in dressing as needed.
c. Dispose of the unmelted ice in a sink.
d. Have the patient perform appropriate therapeutic exercise or apply tape or
compression wrap as indicated.
e. Clean the treatment area and equipment according to normal protocol.
7. Assess treatment efficacy.
a. Ask the patient how the treated area feels.
b. Visually inspect the treated area for any adverse reactions (e.g., wheals,
welts).
c. Perform functional tests as indicated.
252 THERMAL MODALITIES

LAB ACTIVITY
COLD WHIRLPOOL
DESCRIPTION:

A whirlpool is a tank filled with water of a particular temper- on. Using the turbine insures that a layer of warm water does
ature, depending on the desired therapeutic effect. The tank not develop adjacent to the skin, thus providing a more effec-
also contains a turbine or pump that creates convection cur- tive cooling of the tissues. Because the limb is in a dependent
rents in the water. Although water that is any temperature position, any effect of the cooling on decreasing soft tissue
below the temperature of the body surface could be consid- swelling may be negated; using a compression bandage during
ered “cold,” generally water at 10 to 16°C is used. Because the treatment may help in reducing the effects of dependency.
water from the tap is rarely this cold, ice must be added to the As with a warm whirlpool, the patient should not be left
tank. Crushed ice results in the most rapid cooling of the unattended and should be warned against touching any part
water, and all ice must be melted before the turbine is turned of the turbine.

PHYSIOLOGIC EFFECTS:
Vasoconstriction
Superficial anesthesia
Decreased local metabolism
Decreased connective tissue elasticity

THERAPEUTIC EFFECTS:
Decreased or prevented swelling
Decreased pain
Decreased inflammation
Decreased secondary tissue damage

INDICATIONS:
The principal indication for a cold whirlpool is to provide therapeutic cooling of a
larger area of the body than can be achieved readily with an ice or cold pack. Also,
irregularly shaped areas of the body can be treated with total contact. In addition, the
patient can perform active exercise during the application, or the therapist can perform
joint mobilization on the injured limb while immersed in the water.
In addition, use of a cold whirlpool may minimize inflammation and swelling fol-
lowing a therapeutic exercise session. The advantage of a cold whirlpool over an ice or
cold pack is the greater area that can be treated; a disadvantage is the possibility of
increased swelling when the limb is in a dependent position.

CONTRAINDICATIONS:
• Lack of normal temperature sensibility
• Cold hypersensitivity (urticaria or hemoglobinuria)
• Vasospastic disorders (e.g., Raynaud’s disease)
• Coronary artery disease
• Hypertension
INFRARED MODALITIES 253

COLD WHIRPOOL
PROCEDURE Evaluation
1 2 3
1. Check supplies and equipment.
a. Obtain towels for padding the edge of the whirlpool tank, as well as for
drying the treated part.
b. Check temperature of tank, insure all ice is melted before applying treat-
ment.
c. Position chair of correct height next to whirlpool.
2. Question patient.
a. Verify identity of patient (if not already verified).
b. Verify the absence of contraindications.
c. Ask about previous cryotherapy or whirlpool treatments, check treatment
notes.
3. Position patient.
a. Have patient sit on chair with body part out of water.
b. Expose body part to be treated.
c. Drape patient to preserve patient’s modesty, protect clothing, but allow
access to body part.
4. Inspect body part to be treated.
a. Check light touch perception.
b. Check circulatory status (pulses, capillary refill).
c. Verify that there are no open wounds or rashes.
d. Assess function of body part (e.g., ROM, irritability).
5. Administer cold whirlpool.
a. Pad edge of tank with toweling, warn patient that the water is cold, then
place body part in water.
b. Instruct patient to keep away from all parts of the turbine.
c. Turn on the turbine, adjust the aeration, agitation, and direction of the
water being pumped.
d. Check the patient’s response verbally and visually about every 2 minutes.
Remind the patient to tell you if the area starts hurting or if sensation is
lost.
6. Complete the treatment.
a. Turn off the turbine at the completion of the treatment time.
b. Remove the body part from the water and dry it off.
c. Assist the patient in dressing as needed and instruct in therapeutic exer-
cise as indicated.
d. Clean the treatment area and equipment according to normal protocol.
7. Assess treatment efficacy.
a. Ask the patient how the treated area feels.
b. Visually inspect the treated area for any adverse reactions (e.g., wheals,
welts).
c. Perform functional tests as indicated.
254 THERMAL MODALITIES

LAB ACTIVITY
VAPOCOOLANT COLD SPRAY
DESCRIPTION:

Vapocoolant sprays, such as Fluori-Methane are liquids that Fluori-Methane, a mixture of 85% trichloromonofluo-
are sprayed on the skin. Thermal energy from the body is romethane and 15% dichlorodifluoromethane, is not flamma-
absorbed by the liquids, which have low boiling points; there- ble and is nontoxic. Ethyl chloride is flammable, and there-
fore, the liquid almost immediately evaporates. As it evapo- fore is not recommended for use.
rates, thermal energy is removed from the body, resulting in a
superficial cooling.

PHYSIOLOGIC EFFECTS:
Superficial anesthesia

THERAPEUTIC EFFECTS:
Inhibition of painful trigger points
Decrease in pain with stretching musculotendinous tissue

INDICATIONS:
Vapocoolant sprays are used mostly for the treatment of trigger points and for stretch-
ing of tight musculotendinous tissue. Trigger points are a poorly understood phenome-
non, but many pain syndromes are ascribed to active trigger points. Two relatively com-
mon treatments for trigger points are deep friction massage (similar to vigorous
acupressure) and stretching of the muscle the trigger point is located within. Because
direct pressure on and stretching of the trigger points is painful, the area can be sprayed
with a vapocoolant to decrease the pain during the treatment.
In a similar manner, if a musculotendinous strain has resulted in a loss of range of
motion, spraying the skin over the injured muscle may decrease the pain perception
while the therapist stretches the body part. Care must be taken to not overstretch the
tissue and produce further injury.

CONTRAINDICATIONS:
• Lack of normal temperature sensibility
• Cold hypersensitivity (urticaria or hemoglobinuria)
• Vasospastic disorders (e.g., Raynaud’s disease)

VAPOCOOLANT COLD SPRAY

PROCEDURE Evaluation
1 2 3
1. Check supplies.
a. Obtain vapocoolant.
b. Obtain toweling or other draping materials needed.
2. Question patient.
a. Verify identity of patient (if not already verified).
b. Verify the absence of contraindications.
c. Ask about previous cryotherapy treatments, check treatment notes.
INFRARED MODALITIES 255

PROCEDURE Evaluation
1 2 3
3. Position patient.
a. Place patient in a well-supported, comfortable position.
b. Expose body part to be treated.
c. Drape patient to preserve patient’s modesty, protect clothing, but allow
access to body part.
4. Inspect body part to be treated.
a. Check light touch perception.
b. Check circulatory status (pulses, capillary refill).
c. Verify that there are no open wounds or rashes.
d. Assess function of body part (e.g., ROM, irritability).
5. Apply vapocoolant.
a. Position body part such that the area to be treated is on a stretch.
b. Protect the patient’s eyes and insure the patient does not inhale fumes.
c. Holding the vapocoolant upside down, with the nozzle at about a 30°
angle from the perpendicular with the skin, and about 45 cm from the
skin, spray the skin from distal to proximal.
d. Spray in one direction only 3 to 4 times, then apply direct pressure or
increased stretch as indicated and tolerated by the patient. Repeat the pro-
cedure as needed after the skin has rewarmed.
e. Check the patient’s response frequently during the treatment.
6. Complete treatment.
a. On attainment of the desired therapeutic effect (or up to 4 repetitions of
spray-and-stretch or pressure or to patient tolerance), inspect the treated
body part for adverse reactions.
b. Remove draping materials, assist the patient in dressing as needed.
c. If further therapeutic exercise is indicated, instruct the patient to perform
it.
d. Clean the treatment area and equipment according to normal protocol.
7. Assess treatment efficacy.
a. Ask the patient how the treated area feels.
b. Visually inspect the treated area for any adverse reactions (e.g., wheals,
welts).
c. Perform functional tests as indicated.
256 THERMAL MODALITIES

LAB ACTIVITY
CONTRAST BATH
DESCRIPTION:

A contrast bath involves the alternating immersion of the during a single treatment session. A suggested sequence is to
involved body part in warm water and cold water. Usually, the start with 3 minutes in warm, followed by 1 minute in cold,
wrist and hand or foot and ankle are treated, though the with the sequence repeated five times (e.g., 3W-1C-3W-1C-
entire upper or lower member could be treated using two 3W-1C-3W-1C-3W-1C); however, some therapists recom-
whirlpool tanks. The duration of immersion in each tempera- mend starting and ending with warm water. The warm water
ture water is variable, as is the number of times immersed should be 40 to 41°C, and the cold water 10 to 16°C.

PHYSIOLOGIC EFFECTS:
Alternating vasodilation and vasoconstriction

THERAPEUTIC EFFECTS:
Variable effects on swelling
Decreased pain

INDICATIONS:
Contrast baths are often used in the subacute and chronic stages of recovery. Most
of the information regarding benefits of contrast baths is anecdotal; there is little
research documenting the efficacy of this treatment.

CONTRAINDICATIONS:
• Lack of normal temperature sensibility
• Cold hypersensitivity (urticaria or hemoglobinuria)
• Vasospastic disorders (e.g., Raynaud’s disease)

CONTRAST BATH
PROCEDURE Evaluation
1 2 3
1. Check supplies and equipment.
a. Obtain towels, containers, ice, timer, and so on.
b. Check temperature of water in each container.
2. Question patient.
a. Verify identity of patient (if not already verified).
b. Verify the absence of contraindications.
c. Ask about previous cryotherapy or thermotherapy, treatments, check treat-
ment notes.
3. Position patient.
a. Have patient sit in a comfortable position.
b. Expose body part to be treated.
c. Drape patient to preserve patient’s modesty, protect clothing, but allow
access to body part.
INFRARED MODALITIES 257

PROCEDURE Evaluation
1 2 3
4. Inspect body part to be treated.
a. Check light touch perception.
b. Check circulatory status (pulses, capillary refill).
c. Verify that there are no open wounds or rashes.
d. Assess function of body part (e.g., ROM, irritability).
5. Administer contrast bath.
a. Set timer for appropriate interval, help patient immerse body part fully
into warm water; start timer.
b. After the timer goes off, set it for the next interval. Warn patient that the
cold water will feel very cold; help patient immerse body part fully into
cold water; start timer.
c. Continue the cycles until the treatment is complete. Usually, the patients
can time each immersion themselves.
d. Check the patient’s response verbally and visually about every 2 minutes.
Remind the patient to tell you if the area starts hurting or if sensation is
lost.
6. Complete the treatment.
a. Remove the body part from the water and dry it off.
b. Assist the patient in dressing as needed and instruct in therapeutic exercise
as indicated.
c. Clean the treatment area and equipment according to normal protocol.
7. Assess treatment efficacy.
a. Ask the patient how the treated area feels.
b. Visually inspect the treated area for any adverse reactions (e.g., wheals,
welts).
c. Perform functional tests as indicated.
258 THERMAL MODALITIES

LAB ACTIVITY
CRYO-CUFF
DESCRIPTION:

Description: ankle, knee, and shoulder. A major advantage of a Cryo-Cuff

A Cryo-Cuff has three parts: a cuff that holds chilled is that the cuff can conform to a joint’s unique shape, provid-
water, a cooler that holds water and ice, and a connecting ing both cold and compression simultaneously.
tube. Cuffs are fabricated for numerous body joints including

Physiologic Effects:
Superficial anesthesia
Decreased local metabolism

Therapeutic Effects:
Decreased swelling
Decreased pain
Decreased inflammation

Indications:
The primary indication for the use of a Cryo-Cuff is in the acute phase of a soft-
tissue injury or immediately following surgery of a joint. The cooling and compression
of the injured area will provide analgesia and help prevent the development of edema or
effusion. The Cryo-Cuff may assist in the resolution of swelling by altering the Star-
ling-Landis forces at the capillary bed.
A Cryo-Cuff is also useful in minimizing or preventing increased inflammation or
pain following a session of therapeutic exercise. The depth of anesthesia achieved with
a Cryo-Cuff is generally considerably less than with an ice massage.

Contraindications:
• Lack of normal temperature sensibility
• Cold hypersensitivity (urticaria or hemoglobinuria)
• Vasospastic disorders (e.g., Raynaud’s disease)
• Coronary artery disease
• Hypertension

CRYO/CUFF
PROCEDURE Evaluation
1 2 3
1. Check supplies.
a. Obtain wet towel to wrap joint in, an appropriate amount of ice to fill
cooler, and a sheet or towels for draping.
b. Add water and ice to cooler for appropriate mix.
2. Question patient.
a. Verify identity of patient (if not already verified).
b. Verify the absence of contraindications.
c. Ask about previous cryotherapy treatments, check treatment notes.
INFRARED MODALITIES 259

PROCEDURE Evaluation
1 2 3
3. Position patient.
a. Place patient in a well-supported, comfortable position.
b. Expose the joint to be treated.
c. Drape patient to preserve patient’s modesty, protect clothing, but allow
access to body part.
4. Inspect joint to be treated.
a. Check light touch perception.
b. Check circulatory status (pulses, capillary refill).
c. Verify that there are no open wounds or rashes.
d. Assess function of body part (e.g., ROM, irritability).
5. Apply empty Cryo-Cuff to joint as indicated, close Velcro straps, and connect
tubing from cooler to cuff.
a. Warn the patient that you are going to fill the Cryo-Cuff, and then do so
by opening cooler air vent and raising the cooler above the cuff until the
cuff is full. Close the cooler air vent. Elevate the joint as required.
b. Set a timer for the appropriate treatment time (generally about 15 min),
and give the patient a signaling device. Make sure the patient understands
how to use the signaling device.
c. Check the patient’s response verbally after the first 2 minutes, then about
every 5 minutes. Perform a visual check of the area if the patient reports
any unusual sensation. If wheals or welts appear, or if the skin color
changes to absolute white within the first 4 minutes of treatment, stop the
treatment.
d. Rechill cuff as needed. Reconnect tube to cuff, open air vent, lower cooler
to floor and completely drain water from cuff. Allow water to rechill, then
repeat filling cuff.
6. Complete the treatment.
a. When the treatment time is over, remove the Cryo-Cuff and dry the area
with a towel.
b. Remove material used for draping, assist the patient in dressing as needed.
c. Have the patient perform appropriate therapeutic exercise as indicated.
d. Clean the treatment area and equipment according to normal protocol.
7. Assess treatment efficacy.
a. Ask the patient how the treated area feels.
b. Visually inspect the treated area for any adverse reactions.
c. Perform functional tests as indicated.
260 THERMAL MODALITIES

LAB ACTIVITY
WARM WHIRLPOOL
DESCRIPTION:

A whirlpool is a tank filled with water of a particular temper- more uniform warming. Because of the dependent position of
ature, depending on the desired therapeutic effect. The tank the body part in the whirlpool and the increased temperature
also contains a turbine or pump that creates convection cur- of the body part, a warm whirlpool may increase soft tissue
rents in the water. Although water that is any temperature swelling; even in noninjured limbs, there may be a consider-
above the temperature of the body surface could be consid- able increase in interstitial fluid following a warm whirlpool.
ered “warm,” generally water at 35 to 43°C is used. If the Because the turbine is powered by electricity, it is gener-
entire body is to be immersed, temperatures above 38°C ally prudent to not let the patient touch any part of the tur-
should not be used to avoid interference with thermoregula- bine. Also, patients should not be left in the whirlpool unat-
tion. The use of the turbine avoids the development of a layer tended; this is true whether the entire body or only a limb is
of cooler water adjacent to the body part, thus producing immersed.

PHYSIOLOGIC EFFECTS:
Vasodilation
Decreased pain perception
Increased local metabolism
Increased connective tissue plasticity
Decreased isometric strength (transient)

THERAPEUTIC EFFECTS:
Decreased pain
Increased soft tissue extensibility
Sedative

INDICATIONS:
The principal indication for a warm whirlpool is to provide therapeutic warming of a
larger area of the body than can be achieved readily with a hot pack. The effective depth
of therapeutic heating is the same at approximately 1 cm. In addition, the patient can
perform active exercise during the application, or the therapist can perform joint mobi-
lization on the injured limb while immersed in the water. Some therapists use
whirlpool for cleaning a limb after removal of a cast; equally effective and at less cost is
a shower.
The primary therapeutic effect of superficial heating is to increase the ability of the
collagen to remodel. Therefore, heating the tissue is beneficial following a period of
reduced mobility if the soft tissue has shortened. In addition, the tissue viscosity is
reduced, resulting in a greater ease of motion through the available range of motion.

CONTRAINDICATIONS:
• Lack of normal temperature sensibility
• Peripheral vascular disease with compromised circulation
• Over tumors
• Coronary artery disease
INFRARED MODALITIES 261

WARM WHIRLPOOL
PROCEDURE Evaluation
1 2 3
1. Check supplies and equipment.
a. Obtain towels for padding the edge of the whirlpool tank, as well as for
drying the treated part.
b. Check temperature of tank before applying treatment.
c. Position chair of correct height next to whirlpool.
2. Question patient.
a. Verify identity of patient (if not already verified).
b. Verify the absence of contraindications.
c. Ask about previous thermotherapy or whirlpool treatments, check treat-
ment notes.
3. Position patient.
a. Have patient sit on chair with body part out of water.
b. Expose body part to be treated.
c. Drape patient to preserve patient’s modesty, protect clothing, but allow
access to body part.
4. Inspect body part to be treated.
a. Check light touch perception.
b. Check circulatory status (pulses, capillary refill).
c. Verify that there are no open wounds or rashes.
d. Assess function of body part (e.g., ROM, irritability).
5. Administer warm whirlpool.
a. Pad edge of tank with toweling; ask patient to tell you if the water is too
hot, then place body part in water.
b. Instruct patient to keep away from all parts of the turbine.
c. Turn on the turbine, adjust the aeration, agitation, and direction of the
water being pumped.
d. Check the patient’s response verbally and visually about every 2 minutes.
Remind the patient to tell you if the area starts hurting or if sensation is
lost.
6. Complete the treatment.
a. Turn off the turbine at the completion of the treatment time.
b. Remove the body part from the water and dry it off.
c. Assist the patient in dressing as needed and instruct in therapeutic exer-
cise as indicated.
d. Clean the treatment area and equipment according to normal protocol.
7. Assess treatment efficacy.
a. Ask the patient how the treated area feels.
b. Visually inspect the treated area for any adverse reactions (e.g., wheals,
welts).
c. Perform functional tests as indicated.
262 THERMAL MODALITIES

LAB ACTIVITY
HYDROCOLLATOR PACKS
DESCRIPTION:

Commercially available hot packs (“hydrocollator packs”) are covers provide approximately four thicknesses of toweling.
usually a canvas cover filled with a hydrophilic substance such After use, the hot pack should be returned to the cabinet for
as bentonite. Hot packs are kept in a commercial water-filled at least 30 minutes to insure reheating. Hot packs provide
container that maintains a temperature of approximately only superficial heating; the maximum depth of therapeutic
71°C. The packs are wrapped in six to eight layers of dry tow- heating is only about 1 cm, and occurs within 10 minutes of
els to protect the patient from burns; commercial hot pack application.

PHYSIOLOGIC EFFECTS:
Vasodilation
Decreased pain perception
Increased local metabolism
Increased connective tissue plasticity
Decreased isometric strength (transient)

THERAPEUTIC EFFECTS:
Decreased pain
Increased soft tissue extensibility

INDICATIONS:
The principal indication for a hot pack is to provide therapeutic warming of superficial
tissues. Tissues that are deeper than 1 cm do not reach a therapeutic temperature range
of 30 to 40°C. Therefore, if the target tissue is deeper than 1 cm (e.g., the spinal facet
joints), a hot pack will not be effective. Other joints, such as the knee, wrist, and ankle,
can be effectively heated with a hot pack.
The primary therapeutic effect of superficial heating is to increase the ability of the
collagen to remodel. Therefore, heating the tissue is beneficial following a period of
reduced mobility if the soft tissue has shortened. In addition, the tissue viscosity is
reduced, resulting in a greater ease of motion through the available range of motion.
Although generally not a problem, in case of extreme pressure sensitivity, the weight of
a hot pack may be more than the patient can tolerate. In these cases, Fluidotherapy or a
warm whirlpool may be helpful.

CONTRAINDICATIONS:
• Lack of normal temperature sensibility
• Peripheral vascular disease with compromised circulation
• Over tumors
INFRARED MODALITIES 263

HYDROCOLLATOR PACKS
PROCEDURE Evaluation
1 2 3
1. Check supplies.
a. Obtain dry towels to wrap hot pack in, sheet or towels for draping, timer,
signaling device.
b. Check cabinet for appropriate temperature.
2. Question patient.
a. Verify identity of patient (if not already verified).
b. Verify the absence of contraindications.
c. Ask about previous thermotherapy treatments, check treatment notes.
3. Position patient.
a. Place patient in a well-supported, comfortable position.
b. Expose body part to be treated.
c. Drape patient to preserve patient’s modesty, protect clothing, but allow
access to body part.
4. Inspect body part to be treated.
a. Check light touch perception.
b. Check circulatory status (pulses, capillary refill).
c. Verify that there are no open wounds or rashes.
d. Assess function of body part (e.g., ROM, irritability).
5. Apply hot pack.
a. Wrap hot pack in towels to provide six to eight layers of towel between
the hot pack and the patient. If using a commercial hot pack cover, use at
least one layer of towel to keep the cover clean.
b. Inform the patient that you are going to put the hot pack on the body part
to be treated, then do so.
c. Set a timer for the appropriate treatment time and give the patient a sig-
naling device. Make sure the patient understands how to use the signaling
device.
d. Check the patient’s response after the first 5 minutes by asking the patient
how it feels as well as visually checking the area under the hot pack. If the
area is blotchy, additional toweling may be needed. Recheck verbally about
every 5 minutes. A visual inspection every 5 minutes is not inappropriate.
6. Complete the treatment.
a. When the treatment time is over, remove the hot pack and dry the area
with a towel.
b. Remove material used for draping, assist the patient in dressing as needed.
c. Have the patient perform appropriate therapeutic exercise as indicated.
d. Clean the treatment area and equipment according to normal protocol.
7. Assess treatment efficacy.
a. Ask the patient how the treated area feels.
b. Visually inspect the treated area for any adverse reactions.
c. Perform functional tests as indicated.
264 THERMAL MODALITIES

LAB ACTIVITY
PARAFFIN BATH
DESCRIPTION:

Paraffin baths consist of dipping and removing or immersing tration is adequate to warm these joints to a therapeutic
the body part in a mixture of wax and mineral oil. The ratio of range.
wax and mineral oil is about 7 to 1, which results in a sub- The two basic techniques of application of paraffin in-
stance with a melting point of about 47.8°C, a specific heat volve repeated dipping of the body part in the mixture, then
of about 0.65 cal • g⫺1 • °C⫺1, and a therapeutic tempera- covering the body part with plastic and toweling. The advan-
ture range of 48 to 54°C. Because of the low specific heat, tage of this method is that the body part can then be elevated,
much higher temperatures can be tolerated than if water is reducing the potential for swelling. The second method in-
used. The paraffin is kept in a thermostatically controlled volves dipping the body part in the paraffin once, letting it
cabinet. dry for a few seconds, then immersing the body part for the
Paraffin provides a superficial heat, with a depth of ther- duration of the treatment. The advantage of this technique is
apeutic heating of about 1 cm. However, because paraffin is that the source of heat is constant, so the therapeutic temper-
generally used only for the hands and feet, the depth of pene- ature can be maintained for a longer period.

PHYSIOLOGIC EFFECTS:
Vasodilation
Decreased pain perception
Increased local metabolism
Increased connective tissue plasticity
Decreased isometric strength (transient)

THERAPEUTIC EFFECTS:
Decreased pain
Increased soft tissue extensibility

INDICATIONS:
The principal indication for a paraffin bath is to provide therapeutic warming of super-
ficial tissues. This is particularly effective in the hands and feet following a period of
immobilization. The increased connective tissue plasticity that occurs with warming
will enhance the effectiveness of therapeutic exercise.
Paraffin baths are also helpful in alleviation of pain caused by arthritic changes in
the hands and feet. Caution should be exercised in using paraffin (or any heating agent)
during an acute phase of arthritic pain and swelling.

CONTRAINDICATIONS:
• Lack of normal temperature sensibility
• Peripheral vascular disease with compromised circulation
• Over tumors
INFRARED MODALITIES 265

PARAFFIN BATH
PROCEDURE Evaluation
1 2 3
1. Check supplies.
a. Obtain plastic bag and towels to wrap body part in, timer, signaling
device.
b. Check cabinet for appropriate temperature.
2. Question patient.
a. Verify identity of patient (if not already verified).
b. Verify the absence of contraindications.
c. Ask about previous thermotherapy treatments; check treatment notes.
3. Prepare patient.
a. Have patient remove all jewelry from body part, wash well and dry
thoroughly.
b. Explain to the patient that after dipping the body part into the paraffin,
there should be no movement of the body part for the duration of the
treatment.
4. Inspect body part to be treated.
a. Check light touch perception.
b. Check circulatory status (pulses, capillary refill).
c. Verify that there are no open wounds or rashes.
d. Assess function of body part (e.g., ROM, irritability).
5. Apply paraffin.
a. Guide the body part into the paraffin, making sure the patient does not
contact the bottom of the cabinet or the heating coils.
b. After 2 or 3 seconds, remove the body part, and keep it above the paraffin
so that none of the paraffin drips onto the floor. Reimmerse the body part,
and repeat until the appropriate number of dips have been completed, or
reimmerse for the duration of the treatment.
c. Set a timer for the appropriate treatment time and give the patient a sig-
naling device. Make sure the patient understands how to use the signaling
device.
d. Check the patient’s response after the first 5 minutes by asking the patient
how it feels. Recheck verbally about every 5 minutes.
6. Complete the treatment.
a. When the treatment time is over, remove the towel and plastic bag. Help
the patient remove the paraffin, and either return the paraffin to the cabi-
net, or throw away according to local protocol.
b. Have the patient thoroughly wash and dry the body part.
c. Have the patient perform appropriate therapeutic exercise as indicated.
d. Clean the treatment area and equipment according to normal protocol.
7. Assess treatment efficacy.
a. Ask the patient how the treated area feels.
b. Visually inspect the treated area for any adverse reactions.
c. Perform functional tests as indicated.
266 THERMAL MODALITIES

LAB ACTIVITY
INFRARED LAMPS
DESCRIPTION:

Infrared lamps provide superficial (1 mm or less) heating. peutic level. Therefore, their primary effect is one of mild
Because of the extremely limited penetration, they are not analgesia, and their use is very limited.
capable of elevating connective tissue temperatures to a thera-

PHYSIOLOGIC EFFECTS:
Cutaneous vasodilation
Decreased pain perception

THERAPEUTIC EFFECTS:
Decreased pain

INDICATIONS:
The principal indication for infrared lamp heating is localized pain. Elevation of skin
temperature may decrease the perception of pain for a short time.

CONTRAINDICATIONS:
• Lack of normal temperature sensibility
• Peripheral vascular disease with compromised circulation
• Over tumors

INFRARED LAMPS
PROCEDURE Evaluation
1 2 3
1. Check supplies.
a. Obtain sheet or towels for draping, timer, signaling device.
b. Check lamp for frayed power cords, integrity of lamp and shields, and so
on.
2. Question patient.
a. Verify identity of patient (if not already verified).
b. Verify the absence of contraindications.
c. Ask about previous thermotherapy treatments, check treatment notes.
3. Position patient.
a. Place patient in a well-supported, comfortable position.
b. Expose body part to be treated, have patient remove all jewelry from the
area.
c. Drape patient to preserve patient’s modesty, protect clothing, but allow
access to body part.
4. Inspect body part to be treated.
a. Check light touch perception.
b. Check circulatory status (pulses, capillary refill).
c. Verify that there are no open wounds or rashes.
d. Assess function of body part (e.g., ROM, irritability).
INFRARED MODALITIES 267

PROCEDURE Evaluation
1 2 3
5. Apply infrared light.
a. Position lamp such that the bulb is parallel to the body part being treated
(such that the energy will strike the body at a 90° angle), and is 45 to
60 cm away from the patient. Measure and record the distance from the
lamp to the closest part of the body being treated.
b. Inform the patient that they should feel only a mild warmth; if it is hot,
they should inform you. Start the lamp.
c. Set a timer for the appropriate treatment time and give the patient a sig-
naling device. Make sure the patient understands how to use the signaling
device.
d. Check the patient’s response after the first 5 minutes by asking the patient
how it feels as well as visually checking the area being treated. Recheck
visually and verbally about every 5 minutes.
6. Complete the treatment.
a. When the treatment time is over, move the lamp away from the patient;
dry the area with a towel. Turn the intensity control to zero.
b. Remove material used for draping, assist the patient in dressing as needed.
c. Have the patient perform appropriate therapeutic exercise as indicated.
d. Clean the treatment area and equipment according to normal protocol.
7. Assess treatment efficacy.
a. Ask the patient how the treated area feels.
b. Visually inspect the treated area for any adverse reactions.
c. Perform functional tests as indicated.
268 THERMAL MODALITIES

LAB ACTIVITY
FLUIDOTHERAPY
DESCRIPTION:

Fluidotherapy is a device manufactured by Henley Interna- There are several advantages to using Fluidotherapy to
tional of Sugarland, Texas. Heated air is forced through a treat affected hands or feet. The source of heat is constant, so
container filled with cellulose particles; when heated, the cel- the tissue temperature can be maintained at a therapeutic
lulose takes on fluidlike characteristics. The body part to be level for the duration of the treatment. The body part can be
treated is immersed in the cellulose particles, and the particles exercised during the treatment, either actively or passively by
are circulated in the container, thus providing elevation of tis- the therapist. The mechanical stimulation of the skin with the
sue temperature and a mechanical stimulation of the skin. cellulose particles may provide some analgesic effect and may
The temperature of the unit is adjustable within a range of help desensitize the injured area.
about 39 to 48°C.

PHYSIOLOGIC EFFECTS:
Vasodilation
Decreased pain perception
Increased local metabolism
Increased connective tissue plasticity
Decreased isometric strength (transient)

THERAPEUTIC EFFECTS:
Decreased pain
Increased soft tissue extensibility

INDICATIONS:
The principal indication for Fluidotherapy is to provide therapeutic warming of a
larger area of the body than can be achieved readily with a hot pack. In addition, the
patient can perform active exercise during the application, or the therapist can perform
joint mobilization on the injured limb while in the unit.
The primary therapeutic effect of superficial heating is to increase the ability of the
collagen to remodel. Therefore, heating the tissue is beneficial following a period of
reduced mobility if the soft tissue has shortened. In addition, the tissue viscosity is
reduced, resulting in a greater ease of motion through the available range of motion.

CONTRAINDICATIONS:
• Lack of normal temperature sensibility
• Peripheral vascular disease with compromised circulation
• Over tumors
• Coronary artery disease

FLUIDOTHERAPY
PROCEDURE Evaluation
1 2 3
1. Check supplies and equipment.
a. Obtain timer, signaling device, and so on.
b. Check temperature of Fluidotherapy unit before applying treatment.
INFRARED MODALITIES 269

PROCEDURE Evaluation
1 2 3
c. Position chair of correct height next to unit.
2. Question patient.
a. Verify identity of patient (if not already verified).
b. Verify the absence of contraindications.
c. Ask about previous thermotherapy treatments, check treatment notes.
3. Position patient.
a. Have patient remove jewelry from area to be treated and thoroughly wash
and dry area.
b. Have patient sit on chair next to unit.
c. Expose body part to be treated.
d. Drape patient to preserve patient’s modesty, protect clothing, but allow
access to body part.
4. Inspect body part to be treated.
a. Check light touch perception.
b. Check circulatory status (pulses, capillary refill).
c. Verify that there are no open wounds or rashes.
d. Assess function of body part (e.g., ROM, irritability).
5. Administer Fluidotherapy.
a. With the agitation off, open the sleeved portion of the unit.
b. Instruct patient to insert body part into cellulose particles, reminding
them to tell you if the temperature is too hot.
c. Fasten the sleeve around the body part to prevent the cellulose particles
from being blown out of the unit, and start the agitation.
d. Check the patient’s response verbally after about 5 minutes. Remind the
patient to tell you if the heating sensation becomes uncomfortable.
e. Instruct the patient in any indicated therapeutic exercise to be performed
during the treatment.
6. Complete the treatment.
a. Turn off the agitation at the completion of the treatment time.
b. Remove the body part from the unit, having the patient brush or shake off
as much of the cellulose as possible.
c. Assist the patient in dressing as needed and instruct in therapeutic exer-
cise as indicated.
d. Clean the treatment area and equipment according to normal protocol.
7. Assess treatment efficacy.
a. Ask the patient how the treated area feels.
b. Visually inspect the treated area for any adverse reactions (e.g., wheals,
welts).
c. Perform functional tests as indicated.