The Tried and True Blue

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June 2005

By Deborah Couture, DPT, MS, OCS

The use of heat and cold in rehab remains effective and relevant

In recent years, technological marvels have been developed that have advanced the field of rehabilitation exponentially. Yet, despite the effectiveness of these sophisticated tools, they will never supplant the old-fashioned, "tried and true" methods of rehabilitation, such as hot and cold therapy.

In fact, though they are extremely basic modalities, the use of hot therapy and cold therapy remains the cornerstone treatments in the continuum of rehabilitation. Why? The simple answers are because they work and because they are easy to use. And in the end, any treatments this effective will undoubtedly stand the test of time.

While a therapist is deciding whether to use heat or ice, it is important that he or she considers their unique properties and understands the specific patient's rehabilitation objectives.

Both heating and cooling modalities are appropriate during the rehabilitation process after an acute injury to minimize pain and decrease inflammation. However, generally speaking, cooling methods are appropriate within the first 24 to 48 hours after an acute injury to minimize pain and swelling, while heating modalities tend to be more helpful in the subacute and chronic stages of injury.¹

WARMING TREND
When heat is applied to an injury, it dilates small blood vessels in the area, increasing blood flow. The increased blood supply nourishes the tissues with multiple nutrients and oxygen to hasten healing. Heat also reduces pain in an injured area and helps reduce muscle spasm. In addition, heat helps relax a tense tissue and helps improve the tissue's response to stretching.

But heat must be used with caution, as it also increases the chance that small capillaries will leak blood and plasma into soft tissues around the injury. While dilation of the blood vessels and increased blood flow are desirable for healing, capillary leakage is not, as it leads to greater fluid accumulation and swelling, which retards the healing process. To be beneficial, heat should not be applied until the capillaries have had a chance to seal and stop leaking, which usually requires 24 to 48 hours following injury.²

COLD RELIEF
Not surprisingly, ice has the opposite effect of heat. Physiologically, the application of cold decreases the temperature of the skin and tissues just below the skin surface. Cold is a vasoconstrictor, which causes the blood vessels to narrow, decreasing blood flow and resulting in decreased inflammation and edema following severe injury. It is also believed that cold reduces inflammation by inhibiting histamine and scarring agents, limiting secondary tissue damage.¹

Cold also decreases nerve conduction so that the affected area becomes numb. Ultimately, it is an excellent analgesic that carries no side effects. In a rehab regimen, ice is often used after treatment to reduce pain in a mobilized joint and muscle spasm. It also facilitates active or passive joint motion, allowing a return to exercise sooner.²

All health care and rehabilitation professionals are familiar with the use of ice in the rest, ice, compression, and elevation (RICE) treatment. Used in combination immediately after an injury, these four elements can relieve pain, limit swelling, and protect the injured tissue-all of which help speed healing. Healing occurs as the damaged tissue is replaced by collagen.³

APPLICATIONS
Now that the proper use of heat and cold has been established, it is important to understand how these modalities should be applied.

Heat can be generated through a number of methods, including moist heat therapy, hot-water compresses, whirlpools, infrared lamps, short-wave radiation, high-frequency electrical current, ultrasound, paraffin wax, or warm baths. All heating methods produce essentially the same physiological effects. Their only difference is the depth at which they are produced.⁴

Superficial heating modalities, such as moist heat therapy, compresses, and whirlpools, produce heat that penetrates 1 to 5 mm beneath the skin surface. These superficial heating methods can be used for stiffness, soreness, or minor musculoskeletal injuries. Deep-heating modalities, such as ultrasound, elevate tissue temperature up to 5 cm beneath the skin surface. Tissues high in protein content, such as nerves, muscles, tendons, ligaments, and joint capsules, absorb ultrasound energy and may be selectively heated. Deep-heating methods are commonly used for more severe musculoskeletal injuries.¹

Moist heat therapy is the preferred heat medium for rehabilitation professionals, as wet heat seems to penetrate more deeply than dry heat. Plus, wet heat is relatively easy to use in a clinical setting; the therapist need only to grab a heat pack, wrap it, and apply it to the patient's affected area.

The length of time that heat is used varies from person to person, but it usually ranges from 10 to 20 minutes. If heat is being applied to patients with limited sensation, the therapist must be extremely cautious, as the patients will be unable to tell if their skin is burning. A moist heat pack is kept in water that is maintained between 155° and 160°. It is then wrapped in layers of toweling before it is placed on the affected area; some patients like multiple layers, others prefer a single layer. When applied, the temperature of the pack on the skin should be approximately 115° to 118° Fahrenheit. But it is important to note that it ultimately depends on the individual's tolerance and sensitivity to heat. When the ideal level of increased circulation is attained, the skin on the affected area should turn a bright pink.

Each patient's individual temperature preference must be considered with other heating methods as well. Some patients might think that a whirlpool set at 104° is too hot, while others might want it hotter. It is basically dependent on the patient's physical makeup and medical status.

Ultrasound can be effective for directing heat to a specific body part. Therapeutic ultrasound sends vibrating impulses through tissues. These high-frequency waves produce deep heat as well as "micro massage" the tissues to increase blood circulation and enhance muscle relaxation. Ultrasound may be used with cortisone cream in a process called phonophoresis to help decrease acute inflammation.⁵

However, much controversy exists over the clinical effectiveness of ultrasound, the actual depth of penetration, and the degree of temperature change. Controversy also exists about whether it can effectively break up scar tissue.6,7 Also, when ultrasound is used, the therapist must continuously hold the ultrasound head on the patient, which makes multitasking all but impossible.

Paraffin is an effective method for delivering heat, particularly for arthritic hands. Another method is diathermy, which uses short-wave, electromagnetic energy to heat tissues deep below the surface of the skin, to help speed the healing process. The heat of a diathermy unit penetrates deep into the tissues, increasing the healing process because of increased circulation in the affected areas. This increased circulation supplies the nutrients the body needs to heal to the injury, and, coincidentally, increases the range of motion and relaxes muscles, ligaments, and tendons.

Like heat, ice can also be applied in a variety of ways. The traditional ice pack is a well-established method in most rehabilitation settings. Ice pack solutions are stored at 20°. Like moist heat packs, they are usually wrapped in layers of toweling.

Freezing water in paper cups is also popular, as they are convenient to use and also allow the therapist to massage a specific body part. This is handy when the therapist is trying to position the ice on a specific tendon or small joint.

When cold is used to minimize pain and swelling following exercise or a rehabilitation routine, it should be applied for 15 to 30 minutes. If it is applied any longer than that, the patient risks becoming ischemic.

Cryokinetics is the combination of cold and exercise to decrease pain and promote healing. This is most commonly accomplished by combining a cold whirlpool with active exercise. The use of cold during cryokinetics reduces pain, allowing the client to exercise the injured area. It also reduces swelling and ensures consistent cooling to the entire area.¹

It is not unusual to employ both modalities in one rehabilitation session: Heat someone up, stretch them out, and ice them down at the end. Some clinicians try to incorporate both heat and cold modalities through the use of contrast baths, which utilize vasoconstriction caused by cold, and vasodilation caused by heat. The result is a "pumping action" that helps remove waste products and excess fluid from the injured area and decreases swelling.^8,9

There are chemical heat and cold products, but they are not reusable, making them less cost-efficient. What is more, they generally do not generate the desired temperatures.

Interestingly, some of the prevailing wisdom concerning the most effective use of heat and cold is being challenged. It used to be thought that cold should be applied only to acute injuries to reduce swelling and inflammation, and to discourage hemorrhage.⁹

More and more, people understand the proper use of heat and cold. On occasion, I will still see a patient who tells me they put heat on a new fracture or sprain. But for the most part, the public's use of heat and cold modalities is more appropriate. This is due in part to the fact that people are becoming more proactive in their own treatment. What is more, the prevalence of medical information on the Internet is a tremendous help in this regard. As long as hot and cold modalities remain effective, they will remain an important part of the rehab regimen.

Deborah Couture, DPT, MS, OCS, has 20 years' experience in physical therapy. She is a senior therapist at HEALTHSOUTH Sports Medicine and Rehabilitation Center in Danvers, Mass, where she supervises and teaches in the areas of general orthopedics, spine, and occupational rehabilitation and injury prevention. She has recently helped develop a comprehensive spine management program.

REFERENCES

1. Childs J. The use of cold and heat after injury. ACSM's Certified News. 2004;14(2):1-5.

2. Winter Griffith H. Physical therapy methods and techniques (appendix 15). In: Complete Guide to Sports Injuries. Putnam Publishing Group. Available at: www.mdadvice.com/library/sport/sport105.html. Accessed March 21, 2005.

3. Quinn E. RICE—Best for acute injuries. Available at: sportsmedicine.about.com/cs/rehab/a/rice.htm. Accessed March 21, 2005.

4. Heat or ice: which is better and when? Available at: www.hmc.psu.edu/ufc/events/articles/heat%20v.%20ice.htm. Accessed March 21, 2005.

5. Common procedures-treatments. Available at: www.stronghealth.com/services/orthopaedics/disordersandtreatments/functrehab.cfm. Accessed March 21, 2005.

6. Van der Windt DA, Vand der Heijden GJ, Van den Berg SG. Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain. 1999;81:257-271.

7. Baker KG, Robertson VJ, Duck FA. A review of therapeutic ultrasound: biophysical effects. Phys Ther. 2001; 81:1351-1358.

8. Cote DJ, Prentice WE, Hooker DN, Shields EW. Comparison of three treatment procedures for minimizing ankle sprain swelling. Phys Ther. 1998;68:1072-1076.

9. Sigafoos G. Cold therapy: when cold makes more sense than heat. Available at: www.sigafoospt.com/Education/Cold%20Therapy.htm. Accessed March 21, 2005.

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June 2005