Thermotherapy: Difference between revisions

(replace wrong ampersand with single one)
(change of photo for the heat pack instructions)
 
(33 intermediate revisions by 11 users not shown)
Line 2: Line 2:
'''Original Editor '''- [[User:Kirianne Vander Velden|Kirianne Vander Velden]]  
'''Original Editor '''- [[User:Kirianne Vander Velden|Kirianne Vander Velden]]  


'''Lead Editors''' - {{Special:Contributors/{{FULLPAGENAME}}}}    
'''Lead Editors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;</div><blockquote>Welcome to [[Arkansas Colleges of Health Education School of Physical Therapy Musculoskeletal 1 Project|Arkansas Colleges of Health Education School of Physical Therapy Musculoskeletal 1 Project]]. This space was created by and for the students at Arkansas Colleges of Health Education School in the United States. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</blockquote>
<br> </div>  
<br>  


== <span style="line-height: 1.5em;">Definition/Description</span>&nbsp;  ==
== <span style="line-height: 1.5em;">Definition/Description</span>&nbsp;  ==


Thermotherapy consists of application of heat or cold (cryotherapie) for the purpose of changing the cutaneous, intra-articular and core temperature of soft tissue with the intention of improving the symptoms of certain conditions. Cryotherapy and thermotherapy are useful adjuncts for the treatment of musculoskeletal injuries and soft tissue injuries. Using ice or heat as a therapeutic intervention decreases pain in joint and muscle as well as soft tissues and they have opposite effects on tissue metabolism, blood flow, inflammation, edema and connective tissue extensibility. Thermotherapy can be used in rehabilitation facilities or at home. <ref name="Hurley">M. V. Hurley et al., Non-exercise physical therapies for musculoskeletal conditions, Best Practice &amp; Research, Clinical Rheumatology, 2008.
 1C</ref>&nbsp;<ref name="Brosseau">Brosseau L., Yonge K.A., Welch V. et al., Thermotherapy for treatment of osteoarthritis, the Cochrane library, 2003. 1A</ref>&nbsp;<ref name="Petrofsky">Petrofsky J., Berk L., Lee H., Moist heat or dry heat delayed onset muscle soreness, Journal of clinical medicine research, 2013. 2B</ref>&nbsp;<ref name="Scott">Scott F. Nadler, DO, FACSM, Kurt Weingand, PhD, DVM, and Roger J. Kruse, MD; The Physiologic Basis and Clinical Applications of Cryotherapy and Thermotherapy for the Pain Practitioner, pain physician, 2004. 1A</ref>  
Thermotherapy consists of application of heat or cold (cryotherapy) for the purpose of changing the cutaneous, intra-articular and core temperature of soft tissue with the intention of improving the symptoms of certain conditions. Cryotherapy and thermotherapy are useful adjuncts for the treatment of musculoskeletal injuries and soft tissue injuries. Using ice or heat as a therapeutic intervention decreases pain in joint and muscle as well as soft tissues and they have opposite effects on tissue metabolism, blood flow, inflammation, oedema and connective tissue extensibility. Thermotherapy can be used in rehabilitation facilities or at home. <ref name="Hurley">Hurley MV, Bearne LM. [https://www.sciencedirect.com/science/article/pii/S1521694208000028 Non-exercise physical therapies for musculoskeletal conditions.] Best Practice & Research Clinical Rheumatology. 2008 Jun 1;22(3):419-33.</ref>&nbsp;<ref name="Brosseau"/>&nbsp;<ref name="Petrofsky">Petrofsky J, Berk L, Bains G, Khowailed IA, Hui T, Granado M, Laymon M, Lee H. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3808259/ Moist heat or dry heat for delayed onset muscle soreness.] Journal of clinical medicine research. 2013 Dec;5(6):416.</ref>&nbsp;<ref name="Scott">Nadler SF, Weingand K, Kruse RJ. [https://www.researchgate.net/profile/Kurt_Weingand/publication/6928434_The_physiologic_basis_and_clinical_applications_of_cryotherapy_and_thermotherapy_for_the_pain_practitioner/links/5de9271e92851c8364654b91/The-physiologic-basis-and-clinical-applications-of-cryotherapy-and-thermotherapy-for-the-pain-practitioner.pdf The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner.] Pain physician. 2004 Jul 1;7(3):395-400.</ref>  


== Purpose  ==
== Purpose  ==


The goal of thermotherapy is to alter tissue temperature in a targeted region over time for the purpose of inducing a desired biological response. The majority of thermotherapies are designed to deliver the thermal therapy to a target tissue volume with minimal impact on intervening or surrounding tissues.  
The goal of thermotherapy is to alter tissue temperature in a targeted region over time for the purpose of inducing a desired biological response. The majority of thermotherapies are designed to deliver the thermal therapy to a target tissue volume with minimal impact on intervening or surrounding tissues.
 
<br>
 
*'''''Heat:''''' By increasing the temperature of the skin/soft tissue, the blood flow increases by [http://www.physio-pedia.com/index.php?title=Healing vasodilatation]. The metabolic rate and the tissue extensibility will also increase. Heat increases oxygen uptake and accelerates tissue healing, it also increases the activity of destructive enzymes, such as collagenase, and increases the catabolic rate.


<br>
===== Heat =====
By increasing the temperature of the skin/soft tissue, the blood flow increases by [http://www.physio-pedia.com/index.php?title=Healing vasodilatation]. The metabolic rate and the tissue extensibility will also increase. Heat increases oxygen uptake and accelerates tissue healing, it also increases the activity of destructive enzymes, such as collagenase, and increases the catabolic rate.


*'''''Cold:''''' By decreasing the temperature of the skin/soft tissue, the blood flow decreases by [http://www.physio-pedia.com/index.php?title=Healing vasoconstriction]. It will be followed afterwards by a vasodilatation which will prevent against hypoxic damage (hunting reflex: If the cold pack is left on the skin for more than 10 minutes, the blood vessels will dilatate). The tissue metabolism will decrease just like the neuronal excitability, inflammation, conduction rate and tissue extensibility. At joint temperatures of 30°C or lower, the activity of cartilagedegrading enzymes, including collagenase, elastase, hyaluronidase, and protease, is inhibited. the decreased metabolic rate limits further injury and aids the tissue in surviving the cellular hypoxia that occurs after injury.
===== Cold =====
By decreasing the temperature of the skin/soft tissue, the blood flow decreases by [http://www.physio-pedia.com/index.php?title=Healing vasoconstriction]. It will be followed by a vasodilatation which will prevent against hypoxic damage (hunting reflex: If the cold pack is left on the skin for more than 10 minutes, the blood vessels will dilatate). The tissue metabolism will decrease just like the neuronal excitability, inflammation, conduction rate and tissue extensibility. At joint temperatures of 30°C or lower, the activity of cartilage degrading enzymes, including collagenase, elastase, hyaluronidase, and protease, is inhibited. the decreased metabolic rate limits further injury and aids the tissue in surviving the cellular hypoxia that occurs after injury.


<br>  
<br>  
Line 26: Line 22:
[[Image:Modalities.jpg|center|500px]]'''''&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Figure 1:'''''<i>Pathophysiologic effects of topical modalities <ref name="Scott" /></i>  
[[Image:Modalities.jpg|center|500px]]'''''&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Figure 1:'''''<i>Pathophysiologic effects of topical modalities <ref name="Scott" /></i>  


''Both applications can reduce the pain, but when we need to use which application is still the question. Therefore, patient’s preference can be taken into consideration when deciding which thermotherapy tool to use. <ref name="Hurley" />&nbsp;<ref name="Kellogg">D. L. Kellogg Jr., In vivo mechanisms of cutaneous vasodilation and vasoconstriction in humans during thermoregulatory challenges, the American Physiological Society, 2006. 3A</ref>&nbsp;<ref name="Hendee">Hendee W.R., Physics of Thermal Therapy, Fundamentals and Clinical applications, By Taylor and Francis group, 2013.</ref>&nbsp;<ref name="Heinrichs">Heinrichs K., Textbook of medical physiology, Philadelphia, 1986. (chapter 16: superficial thermal modalities).</ref><br>''  
''Both applications can reduce the pain, but the question of when to use which application is still debated. Therefore, patient’s preference can be taken into consideration when deciding which thermotherapy tool to use. <ref name="Hurley" />&nbsp;<ref name="Kellogg">Kellogg Jr DL. [https://journals.physiology.org/doi/abs/10.1152/japplphysiol.01071.2005 In vivo mechanisms of cutaneous vasodilation and vasoconstriction in humans during thermoregulatory challenges.] Journal of applied physiology. 2006 May;100(5):1709-18.</ref>&nbsp;<ref name="Hendee">Hendee W.R., [https://books.google.fi/books?id=KTlTaJoAbCsC&lpg=PP1&ots=YA-HTmwmrY&dq=Hendee%20W.R.%2C%20Physics%20of%20Thermal%20Therapy%2C%20Fundamentals%20and%20Clinical%20applications&lr&pg=PP1#v=onepage&q&f=false Physics of Thermal Therapy, Fundamentals and Clinical applications], By Taylor and Francis group, 2013. </ref>&nbsp;<ref name="Heinrichs"/><br>''  


== Application  ==
== Application  ==


*'''''Heat:''''' Heating of superficial tissues can be achieved using hot packs, wax baths, towels, sunlight, saunas, heat wraps, steam baths/rooms. We can also get the heat in the deeper tissues through electrotherapy ([http://www.physio-pedia.com/Ultrasound_therapy ultrasound], shockwave and infrared radiation).
===== Heat =====
Heating of superficial tissues can be achieved using hot packs, wax baths, towels, sunlight, saunas, heat wraps, steam baths/rooms. Heat can be induced in the deeper tissues through electrotherapy ([http://www.physio-pedia.com/Ultrasound_therapy ultrasound], shockwave and infrared radiation).
 


<br>


*'''''Cold:''''' Cooling is achieved using ice packs, ice baths, cooling gel packs, cold air and sprays. <ref name="Hurley" />&nbsp;<ref name="Brosseau" />
Exercise in warm water, usually called [http://www.physio-pedia.com/Hydrotherapy-Balneotherapy hydrotherapy], aqua therapy or balneotherapy, is a popular and effective treatment<ref name="Choi">Choi YJ, Lee HJ, Do Hyun Lee SY, Lee KH, Yun ST, Kim JM, Kim HJ, Kim JW. [https://synapse.koreamed.org/func/download.php?path=L2hvbWUvdmlydHVhbC9rYW1qZS9zeW5hcHNlL3VwbG9hZC9TeW5hcHNlRGF0YS9QREZEYXRhLzAxNDBhZC9hZC0yNS00NjIucGRm&filename=YWQtMjUtNDYyLnBkZg== Therapeutic effects and immunomodulation of suanbo mineral water therapy in a murine model of atopic dermatitis.] Annals of dermatology. 2013 Nov;25(4):462.</ref> with a pain relief effect for many patients with painful neurologic or musculoskeletal conditions. The warmth of water may block nociception by acting on thermal receptors and mechanoreceptors, thus influencing spinal segmental mechanisms. It gives positive effects on cutaneous barrier homeostasis and a anti-inflammatory activity. In addition, the warmth may enhance blood flow and muscle relaxation. The hydrostatic effect may also relieve pain by reducing peripheral [http://www.physio-pedia.com/Fluid_Excess/Intoxication oedema] and by dampening sympathetic nervous system activity. <ref name="Hiroharu">Kamioka H, Tsutani K, Okuizumi H, Mutoh Y, Ohta M, Handa S, Okada S, Kitayuguchi J, Kamada M, Shiozawa N, Honda T. [https://www.jstage.jst.go.jp/article/jea/advpub/0/advpub_JE20090030/_article/-char/ja/ Effectiveness of aquatic exercise and balneotherapy: a summary of systematic reviews based on randomized controlled trials of water immersion therapies.] Journal of epidemiology. 2010 Jan 5:0910270113-.</ref>&nbsp;<ref name="Eversden">Eversden L, Maggs F, Nightingale P, Jobanputra P. [https://link.springer.com/article/10.1186/1471-2474-8-23 A pragmatic randomised controlled trial of hydrotherapy and land exercises on overall well being and quality of life in rheumatoid arthritis.] BMC musculoskeletal disorders. 2007 Dec;8(1):1-7.</ref>&nbsp;<ref name="Choi" />


<br>  
===== Cold =====
Cooling is achieved using ice packs, ice baths, cooling gel packs, cold air and sprays. <ref name="Hurley" />&nbsp;<ref name="Brosseau" />


In the literature, they describe [http://www.physio-pedia.com/Cryotherapy cryotherapie] (ice application) as an effective treatment for soft tissue injuries. <ref name="Bleakley">Bleakley C.,McDonough S.,MacAuley D., The Use of Ice in the Treatment of Acute Soft-Tissue Injury: A Systematic Review of Randomized Controlled Trials, The American Journal of Sports Medicine; 2004. 1A</ref>&nbsp;<ref name="Tricia">Tricia J. Hubbard et al., Does Cryotherapy Improve Outcomes With Soft Tissue Injury? Journal of Athletic Training, 2004. 1A</ref>&nbsp;<ref name="Scott" />&nbsp;It reduces the swelling, and it will improve the range of motion. However, there are still some doubts if it is actually effective for pain relief. So the application of ice may be useful for a variety of musculoskeletal pains, yet the evidence for its efficacy should be established more convincingly. <ref name="Ernst">Ernst E., Fialka V., Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy, J pain symptoms manage, 1994. 5</ref>&nbsp;<ref name="Amin">Amin A. Algafly, Keith P. George, The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance, Br J Sports Med, 2007. 3B</ref>


Exercise in warm water, usually called [http://www.physio-pedia.com/Hydrotherapy-Balneotherapy hydrotherapy] or [http://www.physio-pedia.com/Hydrotherapy-Balneotherapy balneotherapy], is a popular and effective treatment<ref name="Choi">Choi YJ et al. Therapeutic effects and immunomodulation of suanbo mineral water therapy in a murine model atopic dermatitis. 1B</ref>&nbsp;with a pain relief effect for many patients with painful neurologic or musculoskeletal conditions. The warmth of water may block nociception by acting on thermal receptors and mechanoreceptors, thus influencing spinal segmental mechanisms. It gives positive effects on cutaneous barrier homeostasis and a anti-inflammatory activity. In addition, the warmth may enhance blood flow and muscle relaxation. The hydrostatic effect may also relieve pain by reducing peripheral [http://www.physio-pedia.com/Fluid_Excess/Intoxication edema] and by dampening sympathetic nervous system activity. <ref name="Hiroharu">Hiroharu K., Kiichiro T., Effectiveness of Aquatic Exercise and Balneotherapy: A Summary of Systematic Reviews Based on Randomized Controlled Trials of Water Immersion Therapies, Journal of epidemiology, 2010. 1A</ref>&nbsp;<ref name="Eversden">Eversden L, Maggs F, Nightingale P, Jobanputra P., A pragmatic randomized controlled trial of hydrotherapy and land exercises on overall well-being and quality of life in rheumatoid arthritis, BMC Musculoskeletal Disorders, 2007. 2A</ref>[&nbsp;<ref name="Choi" />  
In the literature, [http://www.physio-pedia.com/Cryotherapy cryotherapy] (ice application) is described as an effective treatment for soft tissue injuries. <ref name="Bleakley">Bleakley C, McDonough S, MacAuley D. [https://journals.sagepub.com/doi/abs/10.1177/0363546503260757 The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials.] The American journal of sports medicine. 2004 Jan;32(1):251-61.</ref>&nbsp;<ref name="Tricia">Hubbard TJ, Denegar CR. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC522152/ Does cryotherapy improve outcomes with soft tissue injury?]. Journal of athletic training. 2004 Jul;39(3):278.</ref>&nbsp;<ref name="Scott" />&nbsp;It reduces the swelling, and improves the range of motion<ref>Adie, S., Kwan, A., Naylor, J. M., Harris, I. A., & Mittal, R. (2012). Cryotherapy following total knee replacement. ''The Cochrane database of systematic reviews'', (9), CD007911. https://doi.org/10.1002/14651858.CD007911.pub2</ref>. However, there are still some doubts whether it is actually effective for chronic pain relief. The application of ice may be useful for a variety of musculoskeletal pains, yet the evidence for its efficacy should be established more convincingly. <ref name="Ernst">Ernst E, Fialka V. [https://www.sciencedirect.com/science/article/pii/0885392494901503 Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy.] Journal of pain and symptom management. 1994 Jan 1;9(1):56-9.</ref>&nbsp;<ref name="Amin">Algafly AA, George KP. [https://bjsm.bmj.com/content/41/6/365.short The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance.] British journal of sports medicine. 2007 Jun 1;41(6):365-9.</ref>  


== Mechanism of Action  ==
== Mechanism of Action  ==
Line 50: Line 47:
'''''&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Figure 2:'''''<i>Skin blood flow responses to cold stress and heat stress. <ref name="Kellogg" />&nbsp;</i>  
'''''&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Figure 2:'''''<i>Skin blood flow responses to cold stress and heat stress. <ref name="Kellogg" />&nbsp;</i>  


<br>VC = vasocondtriction, VD = vasodilatation<br>  
<br>VC = vasoconstriction, VD = vasodilatation<br>  


<span>&nbsp;</span><br>During periods of hypothermia, falling core and skin temperatures lead to reflexive increases in sympathetic active vasoconstrictor nerve activity to reduce skin blood flow and conserve body heat. During periods of heat stress, increasing core and skin temperatures lead to reflexive increases in sympathetic active vasodilator nerve activity to increase skin blood flow.  
<span>&nbsp;</span><br>During periods of hypothermia, falling core and skin temperatures lead to reflexive increases in sympathetic active vasoconstrictor nerve activity to reduce skin blood flow and conserve body heat. During periods of heat stress, increasing core and skin temperatures lead to reflexive increases in sympathetic active vasodilator nerve activity to increase skin blood flow.  
Line 56: Line 53:
The effect of heat on pain is mediated by heat sensitive calcium channels. These channels respond to heat by increasing intracellular calcium. This generates action potentials that increases stimulation of sensory nerves and causes the feeling of heat in the brain. These channels are part of a family of receptors called TRPV receptors. TRPV1 and TRPV2 channels are sensitive to noxious heat, while TRPV4 channels are sensitive to normal physiological heat. Their multiple binding sites allow a number of factors to activate these channels. Once activated, they can also inhibit the activity of purine pain receptors. These receptors, called P2X2 and P2Y2 receptors, are mediated pain receptors and are located in the peripheral small nerve endings. For example, with peripheral pain, heat can directly inhibit pain. However, when pain is originating from deep tissue, heat stimulates peripheral pain receptors which can alter what has been termed gating in the spinal cord and reduce deep pain.  
The effect of heat on pain is mediated by heat sensitive calcium channels. These channels respond to heat by increasing intracellular calcium. This generates action potentials that increases stimulation of sensory nerves and causes the feeling of heat in the brain. These channels are part of a family of receptors called TRPV receptors. TRPV1 and TRPV2 channels are sensitive to noxious heat, while TRPV4 channels are sensitive to normal physiological heat. Their multiple binding sites allow a number of factors to activate these channels. Once activated, they can also inhibit the activity of purine pain receptors. These receptors, called P2X2 and P2Y2 receptors, are mediated pain receptors and are located in the peripheral small nerve endings. For example, with peripheral pain, heat can directly inhibit pain. However, when pain is originating from deep tissue, heat stimulates peripheral pain receptors which can alter what has been termed gating in the spinal cord and reduce deep pain.  


Previous studies have suggested that temperature can affect the exchange between Ca2+ and Na+ in neural cells. They have documented an increase in both pain threshold (PTH) and pain tolerance (PTO) with the use of cooling. <ref name="Lacy">Lacy A. Holowatz et al., Mechanisms of acetylcholine-mediated vasodilatation in young and aged human skin, The Physiological Society, 2005. 3B</ref>&nbsp;<ref name="Amin" />&nbsp;<ref name="Kellogg" />&nbsp;<ref name="Petrofsky" />  
Previous studies have suggested that temperature can affect the exchange between Ca2+ and Na+ in neural cells. They have documented an increase in both pain threshold (PTH) and pain tolerance (PTO) with the use of cooling. <ref name="Lacy">Holowatz LA, Thompson CS, Minson CT, Kenney WL. [https://physoc.onlinelibrary.wiley.com/doi/abs/10.1113/jphysiol.2004.080952 Mechanisms of acetylcholine‐mediated vasodilatation in young and aged human skin.] The Journal of physiology. 2005 Mar;563(3):965-73.</ref>&nbsp;<ref name="Amin" />&nbsp;<ref name="Kellogg" />&nbsp;<ref name="Petrofsky" /><br>Increased superficial tissue temperature results in the release of chemical mediators, such as histamine and prostaglandins, which result in vasodilation. These vasodilatory mechanisms do not significantly affect blood flow in skeletal muscle since skeletal muscle blood flow is heavily influenced by other physiologic and metabolic factors. Exercise is the best means to increase blood flow to skeletal muscle. <ref name="Swenson">Swenson, C., Swärd, L., & Karlsson, J. (1996). Cryotherapy in sports medicine. ''Scandinavian journal of medicine & science in sports'', ''6''(4), 193–200. https://doi.org/10.1111/j.1600-0838.1996.tb00090.x</ref>&nbsp;<ref name="Heinrichs">Heinrichs K. [http://sportsperformance.org/pspi/About_Me_files/heinrichs_cold_hot_physical_therapy_canine.pdf Superficial thermal modalities. InCanine rehabilitation and physical therapy] 2004 Jan 1. Saunders Elsevier, St Louis (MO). </ref>&nbsp;
 
== Treatment  ==
 
Evidence surrounding the use of thermotherapy is mostly limited to the reduction of pain in conditions such as [[osteoarthritis]], [[Rheumatoid Arthritis|rheumatoid arthritis]], [[Primary Dysmenorrhea|primary dysmenorrhea]] and [[Low Back Pain Guidelines|low back pain]]. <ref>Jo, J., & Lee, S. H. (2018). Heat therapy for primary dysmenorrhea: A systematic review and meta-analysis of its effects on pain relief and quality of life. ''Scientific reports'', ''8''(1), 16252. https://doi.org/10.1038/s41598-018-34303-z</ref><ref>Freiwald, J., Hoppe, M. W., Beermann, W., Krajewski, J., & Baumgart, C. (2018). Effects of supplemental heat therapy in multimodal treated chronic low back pain patients on strength and flexibility. ''Clinical biomechanics (Bristol, Avon)'', ''57'', 107–113. https://doi.org/10.1016/j.clinbiomech.2018.06.008</ref><ref>Robinson, V., Brosseau, L., Casimiro, L., Judd, M., Shea, B., Wells, G., & Tugwell, P. (2002). Thermotherapy for treating rheumatoid arthritis. ''The Cochrane database of systematic reviews'', (1), CD002826. https://doi.org/10.1002/14651858.CD002826</ref><ref name="Brosseau" />However, the use of those modalities can facilitate the efficacy of other treatments such as therapeutic exercises by reducing nociceptive signals and reducing joint stiffness (improved range of motion).
 
As for healing properties, the new guidelines suggest avoiding the use of thermotherapy during the stages of healing (see [[Peace and Love Principle]]). There are [[Wound Healing|4 phases]] of the healing process: the hemostasis phase, the inflammatory phase, the proliferation phase and the remodeling phase.<ref>Wound Source. Wound Healing. Available from:https://www.woundsource.com/blog/four-stages-wound-healing</ref>These phases hold their purposes and should only be altered in case of abnormal or extreme symptoms.


True or not true?Disadvantage: when you heat skin, vasodilatation (VD) distracts blood from soft tissue underneath and poor muscle circulation decreases metabolism in the muscles…<br>Increased superficial tissue temperature results in the release of chemical mediators, such as histamine and prostaglandins, which result in vasodilation. These vasodilatory mechanisms do not significantly affect blood flow in skeletal muscle since skeletal muscle blood flow is heavily influenced by other physiologic and metabolic factors. Exercise is the best means to increase blood flow to skeletal muscle. <ref name="Swenson">Swenson C et al. Cryotherapy in sports medicine. Scand J Med Sci Sports. 1996 Aug6(4) 1B</ref>&nbsp;<ref name="Heinrichs">Heinrichs K., Textbook of medical physiology, Philadelphia, 1986. (chapter 16: superficial thermal modalities).</ref>&nbsp;
Below are instructions on how to use various thermotherapy modalities.
[[File:Hydrocollator.pdf|border|none|thumb|579x579px|'''Hydrocollator Pack instructions''']]
[[File:Paraffin instructions.pdf|border|none|thumb|578x578px|'''Paraffin Bath instructions''']]
[[File:Untitled 6.jpg|none|thumb|577x577px|'''Ultrasound Machine instructions''']]


== Treatment ==
<ref name=":0" />
== Physiological Effects ==


The treatment depends on the type of application and the type of disease.<br>There are 3 phases of the healing process: [http://www.physio-pedia.com/Healing the inflammatory phase], [http://www.physio-pedia.com/Healing the proliferation phase] and [http://www.physio-pedia.com/Healing the remodeling phase]. <ref name="Kathleen">Kathleen A. Sluka, PhD, PT, Michelle R. Christy, MPT, Wendy L. Peterson, MPT, Staci L. Rudd, MPT, Stacie M. Troy, MPT, Reduction of pain-related behaviors with either cold or heat treatment in an animal model of acute arthritis, Archives of Physical Medicine and Rehabilitation, March 1999. 3B</ref>&nbsp;<ref name="Fahey">Fahey T.D., Athletic training: principles and practice, Mayfield.</ref>  
Many of the local physiologic effects of heat and cold have been studied thoroughly. For instance, heat increases skin and joint temperature, improves blood circulation and muscle relaxation and decreases joint stiffness. Cold numbs the pain, decreases swelling, constricts blood vessels and blocks nerve impulses to the joints. <ref name="Kathleen">Sluka KA, Christy MR, Peterson WL, Rudd SL, Troy SM. [https://www.sciencedirect.com/science/article/pii/S0003999399901430 Reduction of pain-related behaviors with either cold or heat treatment in an animal model of acute arthritis.] Archives of physical medicine and rehabilitation. 1999 Mar 1;80(3):313-7.</ref>&nbsp;<ref name="Oosterveld">Oosterveld FG, Rasker JJ. [https://onlinelibrary.wiley.com/doi/abs/10.1002/art.1780371104 Effects of local heat and cold treatment on surface and articular temperature of arthritic knees.] Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 1994 Nov;37(11):1578-82.</ref>&nbsp;<ref name="Brosseau">Brosseau L, Yonge KA, Welch V, Marchand S, Judd M, Wells GA, Tugwell P. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004522/abstract Thermotherapy for treatment of osteoarthritis.] Cochrane Database of Systematic Reviews. 2003(4).</ref>  


*The first phase, known as the inflammatory phase, protects the injured area from further injury while the body contains the damaged tissue. During this phase, [http://www.physio-pedia.com/Cryotherapy cryotherapy] can help to reduce swelling. Never use heat during this phase because heat increases the blood flow into the injured area and increases the amount of swelling. The inflammatory phase has a duration of 2 days.<br>
Deep heating is thought to lessen nerve sensitivity, increase blood flow, increase tissue metabolism, decrease muscle spindle sensitivity to stretch, cause muscle relaxation, and increase flexibility. Heat stimulates the cutaneous thermoreceptors that are connected to the cutaneous blood vessels, causing the release of bradykinin which relaxes the smooth muscle walls resulting in vasodilation. Muscle relaxation occurs as a result of a decreased firing rate of the gamma efferents, thus lowering the threshold of the muscle spindles and increasing afferent activity. There is also a decrease in firing of the alpha motor neuron to the extrafusal muscle fiber, resulting in muscle relaxation and decrease in muscle tone. <ref name="William">Prentice Jr WE. [https://www.jospt.org/doi/abs/10.2519/jospt.1982.3.3.133 An electromyographic analysis of the effectiveness of heat or cold and stretching for inducing relaxation in injured muscle.] Journal of Orthopaedic & Sports Physical Therapy. 1982 Jan 1;3(3):133-40.</ref>&nbsp;<ref name="Steven">Peres SE, Draper DO, Knight KL, Ricard MD. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164307/ Pulsed shortwave diathermy and prolonged long-duration stretching increase dorsiflexion range of motion more than identical stretching without diathermy.] Journal of athletic training. 2002 Jan;37(1):43.</ref>  


*During the second phase, the proliferation phase, new tissue and scar tissue are formed. Heat can now be applied to the injured area to facilitate the healing process.<br>
==  Indications, Precautions, Contraindications, and Adverse Effects ==
There are indications, precautions, contraindications, and adverse effects surrounding the use of thermotherapy, that needs to be taken with different clienteles such as children and older people (due to depleted temperature control capacities), and individuals with deprived sensations. Below are some indications, precautions, contraindications, and adverse effects for cryotherapy and thermotherapy. <ref name="Hurley" />&nbsp;<ref name="Oosterveld1">Oosterveld FG, Rasker JJ. [https://www.sciencedirect.com/science/article/pii/S0049017205800022 Treating arthritis with locally applied heat or cold.] InSeminars in arthritis and rheumatism 1994 Oct 1 (Vol. 24, No. 2, pp. 82-90). WB Saunders.</ref>


*The third and final phase, the remodeling phase, is the process of returning to health: the restoration of structure and function of injured or diseased tissues. The healing process includes blood clotting, tissue mending, scarring and bone healing. Heat therapy can also be used during this phase. <ref name="Kathleen" />&nbsp;<ref name="Fahey" />
===== Cold  =====
[[Cryotherapy]] is indicated for various conditions including chronic pain, acute contusions, acute swelling, muscle spasms, and other things. Precautions should be taken to avoid tissue damage, nerve damage, and to help prevent frostbite. To help avoid the previous list, here are some precautions to consider: tissue damage may result when tissue temperature reaches 59 degrees F, frostbite may result if tissue temperature reaches below 39 degrees F. Contraindications to cryotherapy include conditions like sensory disorders, cold intolerance, and paroxysmal cold hemoglobinuria, where exposure could  cause harm to the individual or an increase in symptoms. Adverse effects to cryotherapy could include any of the following: Tissue death due to prolonged vasoconstriction, ischemia, and thromboses in smaller vessels, tissue death from freezing, also appearance of wheals would indicate an adverse response to cryotherapy application.<ref name=":0">Prentice W.E. Cryotherapy and thermotherapy. [https://accessphysiotherapy.mhmedical.com/book.aspx?bookid=2223 Therapeutic Modalities in Rehabilitation], 5e. McGraw-Hill Education. 2017;(9):336-436</ref><ref name=":1">Cameron MH. [https://shop.elsevier.com/books/physical-agents-in-rehabilitation/cameron/978-0-323-76194-9 Physical Agents in Rehabilitation]. 6e. Elsevier Health Sciences; 2021.p.123-223</ref>


== Physiological Effects  ==
===== Heat =====
Indications:


Many of the local physiologic effects of heat and cold have been studied thoroughly. For instance, heat increases skin and joint temperature, improves blood circulation and muscle relaxation and decreases joint stiffness. Cold will numb the pain, decrease swelling, constrict blood vessels and block nerve impulses to the joint. <ref name="Kathleen" />&nbsp;<ref name="Oosterveld">Oosterveld F.G.J., Rasker J.J., Effects of local heat and cold treatment on surface and articular temperature of arthritic knees, American college of rheumatology, 1994. 1B</ref>&nbsp;<ref name="Brosseau">Brosseau L., Yonge K.A., Welch V. et al., Thermotherapy for treatment of osteoarthritis, the Cochrane library, 2003. 1A</ref>
* Subacute and chronic inflammatory condition
* Subacute or chronic pain
* Decreased range of motion
* Facilitate healing
* Muscle guarding
* Muscle spasm
* Myofascial trigger points
* Subacute muscle strain
* Subacute ligament sprain


Deep heating is thought to lessen nerve sensitivity, increase blood flow, increase tissue metabolism, decrease muscle spindle sensitivity to stretch, cause muscle relaxation, and increase flexibility. Heat stimulates the cutaneous thermo receptors that are connected to the cutaneous blood vessels, causing the release of bradykinin which relaxes the smooth muscle walls resulting in vasodilation. Muscle relaxation occurs as a result of a decreased firing rate of the gamma efferents, thus lowering the threshold of the muscle spindles and increasing afferent activity. There is also a decrease in firing of the alpha motorneuron to the extrafusal muscle fibre, resulting in muscle relaxation and decrease in muscle tone. <ref name="William">William E. Prentice, An Electromyographic Analysis of the Effectiveness of Heat or Cold and Stretching for Inducing Relaxation in Injured Muscle, The journal of orthopaedic and sports physical therapy, 1982. 1B</ref>&nbsp;<ref name="Steven">Steven E. Peres, David O. Draper, Kenneth L. Knight, Mark D. Ricard, Pulsed shortwave diathermy and prolonged long-duration stretching increase dorsiflexion range of motion more than identical stretching without diathermy, Journal of Athletic Training, 2003. 2B</ref>
Precautions:


== <br>Precautions  ==
* Pregnancy
* Impaired Circulation
* Cardiac Insufficiency
* Poor Thermal Regulation
* Edema


A very important note that needs to be made is that thermotherapy is safe for people with a normal skin sensation. When a patient has problems with thermal sensitivity, it could be dangerous. They cannot feel if they are being burned due to the application. <ref name="Hurley" />&nbsp;<ref name="Oosterveld1">Oosterveld F.G., Rasker J.J., Treating arthritis with locally applied heat or cold, semin Arthritis Rheum., 1994. 5</ref>
Contraindications:


== <br>Effectiveness  ==
* Acute musculoskeletal conditions
* Recent or potential hemorrhage
* Thrombosis
* Impaired sensation
* Impaired mentation
* Malignant tumor
* Infrared irradiation of the eyes
* Over an open wound


<u>Effectiveness</u> <ref name="Hurley" />&nbsp;<ref name="Oosterveld" />&nbsp;<ref name="Oosterveld1" />
Adverse Effects:


There are still a lot of contradictions if the use of thermotherapy is effective; however, worldwide it is used to reduce the pain.
* Burns
* Fainting
* Bleeding
* Skin and eye damage from infrared radiation<ref name=":0" /><ref name=":1" />


While there is good evidence that exercise relieves pain, improves function, and is cost-effective, evidence supporting the use of non-exercise physiotherapeutic interventions is much weaker. There is some support for the efficacy of thermotherapy, [http://www.physio-pedia.com/Transcutaneous_Electrical_Nerve_Stimulation_(TENS) transcutaneous electrical neuromuscular stimulation (TENS)], and [http://www.physio-pedia.com/Massage massage]. But there is little evidence to support the efficacy of electrotherapy, [http://www.physio-pedia.com/Acupuncture acupuncture] or [http://www.physio-pedia.com/Manual_Therapy manual therapy].  
== Effectiveness ==
There are still contradictions whether the use of thermotherapy is effective or not. However, it is still used worldwide to reduce acute pain and improve mobility - where most of its evidence stands.  


For [http://www.physio-pedia.com/Knee_Osteoarthritis knee osteoarthritis (OA)], ice massage is reported to improve joint movement, pain and function; ice packs can reduce swelling and improve movement but may not relieve pain. In [http://www.physio-pedia.com/Rheumatoid_Arthritis rheumatoid arthritis (RA)], heat or cold packs are reported to have no effect on [http://www.physio-pedia.com/Fluid_Excess/Intoxication edema], pain, movement, strength or function.<br>
While there is good evidence that exercise relieves pain, improves function, and is cost-effective, evidence supporting the use of non-exercise physio-therapeutic interventions is much weaker. There is some support for the efficacy of thermotherapy, [http://www.physio-pedia.com/Transcutaneous_Electrical_Nerve_Stimulation_(TENS) transcutaneous electrical neuromuscular stimulation (TENS)], and [http://www.physio-pedia.com/Massage massage], but there is little evidence to support the efficacy of electrotherapy, [http://www.physio-pedia.com/Acupuncture acupuncture] or [http://www.physio-pedia.com/Manual_Therapy manual therapy].  


<u>Cost effectiveness</u> <ref name="Hurley" />&nbsp;<ref name="Oosterveld" />&nbsp;<ref name="Oosterveld1" />  
For [http://www.physio-pedia.com/Knee_Osteoarthritis knee osteoarthritis (OA)], ice massage is reported to improve joint mobility, pain and function; ice packs can reduce swelling and improve movement but may not relieve pain. In [http://www.physio-pedia.com/Rheumatoid_Arthritis rheumatoid arthritis (RA)], heat or cold packs are reported to have no effect on [http://www.physio-pedia.com/Fluid_Excess/Intoxication oedema], pain, movement, strength or function.<br>


===== Cost effectiveness =====
Despite conflicting evidence, the simple form of thermotherapy is widely recommended for many musculoskeletal conditions because it is a safe, effective, easy-to-apply and well-liked therapy based on anecdotal reports, expert opinion and patient preferences. Interventions that can be self-administered (thermotherapy, [http://www.physio-pedia.com/Transcutaneous_Electrical_Nerve_Stimulation_(TENS) TENS], [http://www.physio-pedia.com/Massage massage]) are more likely to be cost-effective and less burdensome and hence much more attractive long-term management options. Complex thermal therapeutic modalities (heating deeper tissues) require special equipment, supervision and need to be delivered by a therapist, making them less accessible, more costly and higher risk.<br>  
Despite conflicting evidence, the simple form of thermotherapy is widely recommended for many musculoskeletal conditions because it is a safe, effective, easy-to-apply and well-liked therapy based on anecdotal reports, expert opinion and patient preferences. Interventions that can be self-administered (thermotherapy, [http://www.physio-pedia.com/Transcutaneous_Electrical_Nerve_Stimulation_(TENS) TENS], [http://www.physio-pedia.com/Massage massage]) are more likely to be cost-effective and less burdensome and hence much more attractive long-term management options. Complex thermal therapeutic modalities (heating deeper tissues) require special equipment, supervision and need to be delivered by a therapist, making them less accessible, more costly and higher risk.<br>  


Line 98: Line 132:
[[Image:Effectiveness.jpg|center|500px]]  
[[Image:Effectiveness.jpg|center|500px]]  


'''''&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Figure 3:'''''<i>Short- and long-term effectiveness, cost-effectiveness and clinical practicability of</i>''&nbsp;commonly ''''<br>'''''
'''''&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Figure 3:'''''<i>Short- and long-term effectiveness, cost-effectiveness and clinical practicability of</i>''&nbsp;commonly''


''<span>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span>used physical therapy modalities utilized in the management of musculoskeletal conditions. <ref name="Hurley" />''  
''<span>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span>used physical therapy modalities utilized in the management of musculoskeletal conditions. <ref name="Hurley" />''  


''&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;level of evidence: 1C''  
''&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;level of evidence: 1C''  
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox">
<rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1TAHVG_L--CUI8kd0JDxOUQnLROUq2iKuNJ_JGGNHIiLtnZg5u|charset=UTF­8|short|max=10</rss>
</div>


== References  ==
== References  ==
Line 113: Line 144:
<br>  
<br>  


[[Category:Modalities]] [[Category:Cerebral_Palsy]]
[[Category:Interventions]] [[Category:Cerebral_Palsy]]

Latest revision as of 00:10, 11 April 2024

Welcome to Arkansas Colleges of Health Education School of Physical Therapy Musculoskeletal 1 Project. This space was created by and for the students at Arkansas Colleges of Health Education School in the United States. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Definition/Description [edit | edit source]

Thermotherapy consists of application of heat or cold (cryotherapy) for the purpose of changing the cutaneous, intra-articular and core temperature of soft tissue with the intention of improving the symptoms of certain conditions. Cryotherapy and thermotherapy are useful adjuncts for the treatment of musculoskeletal injuries and soft tissue injuries. Using ice or heat as a therapeutic intervention decreases pain in joint and muscle as well as soft tissues and they have opposite effects on tissue metabolism, blood flow, inflammation, oedema and connective tissue extensibility. Thermotherapy can be used in rehabilitation facilities or at home. [1] [2] [3] [4]

Purpose[edit | edit source]

The goal of thermotherapy is to alter tissue temperature in a targeted region over time for the purpose of inducing a desired biological response. The majority of thermotherapies are designed to deliver the thermal therapy to a target tissue volume with minimal impact on intervening or surrounding tissues.

Heat[edit | edit source]

By increasing the temperature of the skin/soft tissue, the blood flow increases by vasodilatation. The metabolic rate and the tissue extensibility will also increase. Heat increases oxygen uptake and accelerates tissue healing, it also increases the activity of destructive enzymes, such as collagenase, and increases the catabolic rate.

Cold[edit | edit source]

By decreasing the temperature of the skin/soft tissue, the blood flow decreases by vasoconstriction. It will be followed by a vasodilatation which will prevent against hypoxic damage (hunting reflex: If the cold pack is left on the skin for more than 10 minutes, the blood vessels will dilatate). The tissue metabolism will decrease just like the neuronal excitability, inflammation, conduction rate and tissue extensibility. At joint temperatures of 30°C or lower, the activity of cartilage degrading enzymes, including collagenase, elastase, hyaluronidase, and protease, is inhibited. the decreased metabolic rate limits further injury and aids the tissue in surviving the cellular hypoxia that occurs after injury.


Modalities.jpg

                                                          Figure 1:Pathophysiologic effects of topical modalities [4]

Both applications can reduce the pain, but the question of when to use which application is still debated. Therefore, patient’s preference can be taken into consideration when deciding which thermotherapy tool to use. [1] [5] [6] [7]

Application[edit | edit source]

Heat[edit | edit source]

Heating of superficial tissues can be achieved using hot packs, wax baths, towels, sunlight, saunas, heat wraps, steam baths/rooms. Heat can be induced in the deeper tissues through electrotherapy (ultrasound, shockwave and infrared radiation).


Exercise in warm water, usually called hydrotherapy, aqua therapy or balneotherapy, is a popular and effective treatment[8] with a pain relief effect for many patients with painful neurologic or musculoskeletal conditions. The warmth of water may block nociception by acting on thermal receptors and mechanoreceptors, thus influencing spinal segmental mechanisms. It gives positive effects on cutaneous barrier homeostasis and a anti-inflammatory activity. In addition, the warmth may enhance blood flow and muscle relaxation. The hydrostatic effect may also relieve pain by reducing peripheral oedema and by dampening sympathetic nervous system activity. [9] [10] [8]

Cold[edit | edit source]

Cooling is achieved using ice packs, ice baths, cooling gel packs, cold air and sprays. [1] [2]


In the literature, cryotherapy (ice application) is described as an effective treatment for soft tissue injuries. [11] [12] [4] It reduces the swelling, and improves the range of motion[13]. However, there are still some doubts whether it is actually effective for chronic pain relief. The application of ice may be useful for a variety of musculoskeletal pains, yet the evidence for its efficacy should be established more convincingly. [14] [15]

Mechanism of Action[edit | edit source]

Skin blood flow is controlled by two branches of the sympathetic nervous system: a noradrenergic vasoconstrictor system and a cholinergic active vasodilator system. These dual sympathetic neural control mechanisms affect the major aspects of thermoregulatory responses over most of the human body’s surface.

 
Cold and heat stress.png

                                                     Figure 2:Skin blood flow responses to cold stress and heat stress. [5] 


VC = vasoconstriction, VD = vasodilatation

 
During periods of hypothermia, falling core and skin temperatures lead to reflexive increases in sympathetic active vasoconstrictor nerve activity to reduce skin blood flow and conserve body heat. During periods of heat stress, increasing core and skin temperatures lead to reflexive increases in sympathetic active vasodilator nerve activity to increase skin blood flow.

The effect of heat on pain is mediated by heat sensitive calcium channels. These channels respond to heat by increasing intracellular calcium. This generates action potentials that increases stimulation of sensory nerves and causes the feeling of heat in the brain. These channels are part of a family of receptors called TRPV receptors. TRPV1 and TRPV2 channels are sensitive to noxious heat, while TRPV4 channels are sensitive to normal physiological heat. Their multiple binding sites allow a number of factors to activate these channels. Once activated, they can also inhibit the activity of purine pain receptors. These receptors, called P2X2 and P2Y2 receptors, are mediated pain receptors and are located in the peripheral small nerve endings. For example, with peripheral pain, heat can directly inhibit pain. However, when pain is originating from deep tissue, heat stimulates peripheral pain receptors which can alter what has been termed gating in the spinal cord and reduce deep pain.

Previous studies have suggested that temperature can affect the exchange between Ca2+ and Na+ in neural cells. They have documented an increase in both pain threshold (PTH) and pain tolerance (PTO) with the use of cooling. [16] [15] [5] [3]
Increased superficial tissue temperature results in the release of chemical mediators, such as histamine and prostaglandins, which result in vasodilation. These vasodilatory mechanisms do not significantly affect blood flow in skeletal muscle since skeletal muscle blood flow is heavily influenced by other physiologic and metabolic factors. Exercise is the best means to increase blood flow to skeletal muscle. [17] [7] 

Treatment[edit | edit source]

Evidence surrounding the use of thermotherapy is mostly limited to the reduction of pain in conditions such as osteoarthritis, rheumatoid arthritis, primary dysmenorrhea and low back pain. [18][19][20][2]However, the use of those modalities can facilitate the efficacy of other treatments such as therapeutic exercises by reducing nociceptive signals and reducing joint stiffness (improved range of motion).

As for healing properties, the new guidelines suggest avoiding the use of thermotherapy during the stages of healing (see Peace and Love Principle). There are 4 phases of the healing process: the hemostasis phase, the inflammatory phase, the proliferation phase and the remodeling phase.[21]These phases hold their purposes and should only be altered in case of abnormal or extreme symptoms.

Below are instructions on how to use various thermotherapy modalities.

Hydrocollator Pack instructions
Paraffin Bath instructions
Ultrasound Machine instructions

[22]

Physiological Effects[edit | edit source]

Many of the local physiologic effects of heat and cold have been studied thoroughly. For instance, heat increases skin and joint temperature, improves blood circulation and muscle relaxation and decreases joint stiffness. Cold numbs the pain, decreases swelling, constricts blood vessels and blocks nerve impulses to the joints. [23] [24] [2]

Deep heating is thought to lessen nerve sensitivity, increase blood flow, increase tissue metabolism, decrease muscle spindle sensitivity to stretch, cause muscle relaxation, and increase flexibility. Heat stimulates the cutaneous thermoreceptors that are connected to the cutaneous blood vessels, causing the release of bradykinin which relaxes the smooth muscle walls resulting in vasodilation. Muscle relaxation occurs as a result of a decreased firing rate of the gamma efferents, thus lowering the threshold of the muscle spindles and increasing afferent activity. There is also a decrease in firing of the alpha motor neuron to the extrafusal muscle fiber, resulting in muscle relaxation and decrease in muscle tone. [25] [26]

Indications, Precautions, Contraindications, and Adverse Effects[edit | edit source]

There are indications, precautions, contraindications, and adverse effects surrounding the use of thermotherapy, that needs to be taken with different clienteles such as children and older people (due to depleted temperature control capacities), and individuals with deprived sensations. Below are some indications, precautions, contraindications, and adverse effects for cryotherapy and thermotherapy. [1] [27]

Cold[edit | edit source]

Cryotherapy is indicated for various conditions including chronic pain, acute contusions, acute swelling, muscle spasms, and other things. Precautions should be taken to avoid tissue damage, nerve damage, and to help prevent frostbite. To help avoid the previous list, here are some precautions to consider: tissue damage may result when tissue temperature reaches 59 degrees F, frostbite may result if tissue temperature reaches below 39 degrees F. Contraindications to cryotherapy include conditions like sensory disorders, cold intolerance, and paroxysmal cold hemoglobinuria, where exposure could cause harm to the individual or an increase in symptoms. Adverse effects to cryotherapy could include any of the following: Tissue death due to prolonged vasoconstriction, ischemia, and thromboses in smaller vessels, tissue death from freezing, also appearance of wheals would indicate an adverse response to cryotherapy application.[22][28]

Heat[edit | edit source]

Indications:

  • Subacute and chronic inflammatory condition
  • Subacute or chronic pain
  • Decreased range of motion
  • Facilitate healing
  • Muscle guarding
  • Muscle spasm
  • Myofascial trigger points
  • Subacute muscle strain
  • Subacute ligament sprain

Precautions:

  • Pregnancy
  • Impaired Circulation
  • Cardiac Insufficiency
  • Poor Thermal Regulation
  • Edema

Contraindications:

  • Acute musculoskeletal conditions
  • Recent or potential hemorrhage
  • Thrombosis
  • Impaired sensation
  • Impaired mentation
  • Malignant tumor
  • Infrared irradiation of the eyes
  • Over an open wound

Adverse Effects:

  • Burns
  • Fainting
  • Bleeding
  • Skin and eye damage from infrared radiation[22][28]

Effectiveness[edit | edit source]

There are still contradictions whether the use of thermotherapy is effective or not. However, it is still used worldwide to reduce acute pain and improve mobility - where most of its evidence stands.

While there is good evidence that exercise relieves pain, improves function, and is cost-effective, evidence supporting the use of non-exercise physio-therapeutic interventions is much weaker. There is some support for the efficacy of thermotherapy, transcutaneous electrical neuromuscular stimulation (TENS), and massage, but there is little evidence to support the efficacy of electrotherapy, acupuncture or manual therapy.

For knee osteoarthritis (OA), ice massage is reported to improve joint mobility, pain and function; ice packs can reduce swelling and improve movement but may not relieve pain. In rheumatoid arthritis (RA), heat or cold packs are reported to have no effect on oedema, pain, movement, strength or function.

Cost effectiveness[edit | edit source]

Despite conflicting evidence, the simple form of thermotherapy is widely recommended for many musculoskeletal conditions because it is a safe, effective, easy-to-apply and well-liked therapy based on anecdotal reports, expert opinion and patient preferences. Interventions that can be self-administered (thermotherapy, TENS, massage) are more likely to be cost-effective and less burdensome and hence much more attractive long-term management options. Complex thermal therapeutic modalities (heating deeper tissues) require special equipment, supervision and need to be delivered by a therapist, making them less accessible, more costly and higher risk.


Effectiveness.jpg

                             Figure 3:Short- and long-term effectiveness, cost-effectiveness and clinical practicability of commonly

                                  used physical therapy modalities utilized in the management of musculoskeletal conditions. [1]

                                                                                       level of evidence: 1C

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 Hurley MV, Bearne LM. Non-exercise physical therapies for musculoskeletal conditions. Best Practice & Research Clinical Rheumatology. 2008 Jun 1;22(3):419-33.
  2. 2.0 2.1 2.2 2.3 Brosseau L, Yonge KA, Welch V, Marchand S, Judd M, Wells GA, Tugwell P. Thermotherapy for treatment of osteoarthritis. Cochrane Database of Systematic Reviews. 2003(4).
  3. 3.0 3.1 Petrofsky J, Berk L, Bains G, Khowailed IA, Hui T, Granado M, Laymon M, Lee H. Moist heat or dry heat for delayed onset muscle soreness. Journal of clinical medicine research. 2013 Dec;5(6):416.
  4. 4.0 4.1 4.2 Nadler SF, Weingand K, Kruse RJ. The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. Pain physician. 2004 Jul 1;7(3):395-400.
  5. 5.0 5.1 5.2 Kellogg Jr DL. In vivo mechanisms of cutaneous vasodilation and vasoconstriction in humans during thermoregulatory challenges. Journal of applied physiology. 2006 May;100(5):1709-18.
  6. Hendee W.R., Physics of Thermal Therapy, Fundamentals and Clinical applications, By Taylor and Francis group, 2013.
  7. 7.0 7.1 Heinrichs K. Superficial thermal modalities. InCanine rehabilitation and physical therapy 2004 Jan 1. Saunders Elsevier, St Louis (MO).
  8. 8.0 8.1 Choi YJ, Lee HJ, Do Hyun Lee SY, Lee KH, Yun ST, Kim JM, Kim HJ, Kim JW. Therapeutic effects and immunomodulation of suanbo mineral water therapy in a murine model of atopic dermatitis. Annals of dermatology. 2013 Nov;25(4):462.
  9. Kamioka H, Tsutani K, Okuizumi H, Mutoh Y, Ohta M, Handa S, Okada S, Kitayuguchi J, Kamada M, Shiozawa N, Honda T. Effectiveness of aquatic exercise and balneotherapy: a summary of systematic reviews based on randomized controlled trials of water immersion therapies. Journal of epidemiology. 2010 Jan 5:0910270113-.
  10. Eversden L, Maggs F, Nightingale P, Jobanputra P. A pragmatic randomised controlled trial of hydrotherapy and land exercises on overall well being and quality of life in rheumatoid arthritis. BMC musculoskeletal disorders. 2007 Dec;8(1):1-7.
  11. Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. The American journal of sports medicine. 2004 Jan;32(1):251-61.
  12. Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft tissue injury?. Journal of athletic training. 2004 Jul;39(3):278.
  13. Adie, S., Kwan, A., Naylor, J. M., Harris, I. A., & Mittal, R. (2012). Cryotherapy following total knee replacement. The Cochrane database of systematic reviews, (9), CD007911. https://doi.org/10.1002/14651858.CD007911.pub2
  14. Ernst E, Fialka V. Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy. Journal of pain and symptom management. 1994 Jan 1;9(1):56-9.
  15. 15.0 15.1 Algafly AA, George KP. The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. British journal of sports medicine. 2007 Jun 1;41(6):365-9.
  16. Holowatz LA, Thompson CS, Minson CT, Kenney WL. Mechanisms of acetylcholine‐mediated vasodilatation in young and aged human skin. The Journal of physiology. 2005 Mar;563(3):965-73.
  17. Swenson, C., Swärd, L., & Karlsson, J. (1996). Cryotherapy in sports medicine. Scandinavian journal of medicine & science in sports, 6(4), 193–200. https://doi.org/10.1111/j.1600-0838.1996.tb00090.x
  18. Jo, J., & Lee, S. H. (2018). Heat therapy for primary dysmenorrhea: A systematic review and meta-analysis of its effects on pain relief and quality of life. Scientific reports, 8(1), 16252. https://doi.org/10.1038/s41598-018-34303-z
  19. Freiwald, J., Hoppe, M. W., Beermann, W., Krajewski, J., & Baumgart, C. (2018). Effects of supplemental heat therapy in multimodal treated chronic low back pain patients on strength and flexibility. Clinical biomechanics (Bristol, Avon), 57, 107–113. https://doi.org/10.1016/j.clinbiomech.2018.06.008
  20. Robinson, V., Brosseau, L., Casimiro, L., Judd, M., Shea, B., Wells, G., & Tugwell, P. (2002). Thermotherapy for treating rheumatoid arthritis. The Cochrane database of systematic reviews, (1), CD002826. https://doi.org/10.1002/14651858.CD002826
  21. Wound Source. Wound Healing. Available from:https://www.woundsource.com/blog/four-stages-wound-healing
  22. 22.0 22.1 22.2 Prentice W.E. Cryotherapy and thermotherapy. Therapeutic Modalities in Rehabilitation, 5e. McGraw-Hill Education. 2017;(9):336-436
  23. Sluka KA, Christy MR, Peterson WL, Rudd SL, Troy SM. Reduction of pain-related behaviors with either cold or heat treatment in an animal model of acute arthritis. Archives of physical medicine and rehabilitation. 1999 Mar 1;80(3):313-7.
  24. Oosterveld FG, Rasker JJ. Effects of local heat and cold treatment on surface and articular temperature of arthritic knees. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 1994 Nov;37(11):1578-82.
  25. Prentice Jr WE. An electromyographic analysis of the effectiveness of heat or cold and stretching for inducing relaxation in injured muscle. Journal of Orthopaedic & Sports Physical Therapy. 1982 Jan 1;3(3):133-40.
  26. Peres SE, Draper DO, Knight KL, Ricard MD. Pulsed shortwave diathermy and prolonged long-duration stretching increase dorsiflexion range of motion more than identical stretching without diathermy. Journal of athletic training. 2002 Jan;37(1):43.
  27. Oosterveld FG, Rasker JJ. Treating arthritis with locally applied heat or cold. InSeminars in arthritis and rheumatism 1994 Oct 1 (Vol. 24, No. 2, pp. 82-90). WB Saunders.
  28. 28.0 28.1 Cameron MH. Physical Agents in Rehabilitation. 6e. Elsevier Health Sciences; 2021.p.123-223