Assisting with cold and heat therapies

Cold and heat therapeutic modalities or treatments are used for orthopedic injuries and infections. The applications can be as follows:

• Dry: No moisture is left on the skin. Dry applications tend to pull moisture out of the skin.
• Moist: Moisture is left on the skin. Moist applications tend to increase tissue elasticity and allow heat or cold to penetrate deeper into the tissues.
• When using heat or cold applications, the medical assistant should ask the patient if it feels too hot or too cold. The medical assistant should monitor the area being treated. Some patients are at higher risk for tissue injury with heat or cold applications:
• Younger children because of their thinner skin
• Older adults due to their reduced sensitivity to pain
• People with impaired circulation (e.g., those with peripheral vascular diseases and diabetes mellitus)
• People with altered sensitivity (e.g., those who are confused or have neurologic disorders, including diabetic neuropathy and spinal cord damage)
• Those for whom the application is placed on an open wound, broken skin, or stoma (this tissue is more sensitive)
• Those for whom the application is placed on edematous or scarred areas (scars and edema reduce sensitivity)

Patient education for cold and heat applications

• Know what supplies are required and where they can be purchased.
• Use a protective covering between the skin and the application.
• Never fall asleep with an application on the skin.
• Never place an application over metal jewelry.
• Know the length of time for each application, the number of times a day ordered, and the number of days for treatment.
• Heat and cold therapy should be applied for 15 to 20 minutes. Additional time can harm the tissues.
• After the session, remove the application. Allow the skin to return to its normal temperature before applying again.
• Prolonged erythema or paleness, pain, swelling, and blisters should be reported to the provider.

Cold therapy

Cold therapy is typically used for sprains, strains, fractures, joint injuries, shin splints, and other injuries. In some facilities, it is a common practice to provide a cold pack to a patient who comes in with a recent injury.

A cold application causes vasoconstriction, which reduces blood flow to the area. As a result, tissue metabolism decreases, less oxygen is used, and less swelling occurs. The nerve endings in the area become numb. The blood viscosity increases, which can cause clotting. Cold therapy helps to reduce pain and inflammation and prevents edema (swelling) in the injured area.

Heat therapy

Heat therapy can be used to relieve the following conditions:

• Acute pain (e.g., back and menstrual) and chronic pain (e.g., arthritis)
• Sinus congestion
• Infection (e.g., localized abscesses)

Heat therapy can help with muscle relaxation. It can produce local vasodilation, which increases circulation. The increased blood supply to a local area helps to absorb the extra fluid (from edema). Additional types of heat therapy will be discussed.

Paraffin bath therapy

Paraffin provides deep heat therapy. The heat can reduce pain and tenderness. It has been found to maintain muscle strength and increase mobility. Paraffin therapy is a common treatment for arthritis and other conditions that cause pain and stiffness.

Types of cold applications:

Type	Dry or Moist	Description
Cold compress	Moist	Washcloth or other soft cloth is dampened with a cold solution (e.g., water) and applied to the skin.
Chemical cold pack	Dry	Comes in a variety of sizes. Stored at room temperature. Contains inner areas of a dry chemical and water. When activated, the water and chemical mix creates coldness.
Ice bag	Dry	A bag with cubes or pieces of ice.
Gel pack	Dry	Aqueous gel that freezes. Reusable. Stored in freezer.
Bead pack	Dry	Little beads of gel conform to the site even when frozen. Similar to a frozen bag of peas. Reusable. Stored in freezer.

Types of hot applications

Type	Dry or Moist	Description
Hot soak/ whirlpool bath (Hydrotherapy)	Moist	Part of the body is submerged in warm water or a warm medicated solution. Should be warmed to 105°F to 110°F (40.6°C to 43.3°F).
Hot compress	Moist	Washcloth or other soft cloth is dampened with a hot solution (e.g., water) and applied to the skin.
Heating pad	Dry	Electric pad that warms. Inspect for safety purposes.
Chemical hot pack	Dry	Comes in a variety of sizes. Stored at room temperature. Contains inner areas of a dry chemical and water. When activated, the water and chemical mix, creating heat for a period of time.
Gel pack	Dry	Aqueous gel that can be microwaved. Reusable.
Bead pack	Dry	Little beads of gel that can be microwaved. Reusable.

A paraffin bath uses melted paraffin and mineral oil warmed to about 125°F (51.7°C). The patient bathes a foot or hand in the bath. Once the extremity is coated, the patient should lift it out and let it dry for a few seconds. This process is repeated until the patient has 10 to 12 layers of wax built up on the extremity. The foot or hand is wrapped in plastic and then in a towel to retain the moisture and heat. After 20 minutes, it is unwrapped, and the wax is removed.

Heat lamp therapy

Two commonly used heat lamp therapies are red light therapy and near infrared light therapy. Red light therapy is used to treat skin conditions. Near infrared light therapy penetrates deeper, killing pathogens, healing tissue, improving circulation, and relieving pain.

Physical therapy treatments

Different physical therapy treatments can be used to help treat musculoskeletal conditions. The medical assistant should be familiar with the treatments.

Ultrasound therapy

Ultrasound therapy has been used for a long time to treat pain and promote healing. The ultrasound transducer head produces sound waves. Ultrasound gel is applied to the skin. As the transducer head is moved over the skin, the gel helps with the transmission of sound waves into the soft tissue. There are two main types of ultrasound therapy: thermal and mechanical. The main difference between these types is the speed at which the sound waves penetrate the soft tissue. Ultrasound therapy must be done by a trained therapist. This treatment is often provided in chiropractic, sports medicine, physical therapy, and occupational therapy facilities.

RICE therapy

For orthopedic injuries, RICE is commonly ordered as a treatment, usually for the first 48 to 72 hours. After 72 hours, moist heat is prescribed. Here is what RICE stands for:

• Rest: Reduce activities for a period of time. Crutches can help an injured leg/ankle rest.
• Ice: Apply a cold pack to the injured area for 15 to 20 minutes, four to eight times daily.
• Compression: Use elastic bandage (e.g., ACE Wrap) or splints to reduce swelling. It is important to monitor the CMST of a wrapped extremity.
• Elevation: Elevate the injured extremity higher than the level of the heart to reduce swelling.

Exercise therapy

Often patients are encouraged to exercise to maintain their strength and joint mobility. Patients recovering from surgery (e.g., orthopedic, cardiac) may need to see a physical therapist or an occupational therapist. These therapists work with patients to help them regain their mobility and strength. Isometric, isotonic, and range-of-motion exercises are encouraged to maintain strength, flexibility, and mobility.

Isometric contractions do not change the muscle length, but they do increase the muscle tension. Isometric exercises help to maintain a person’s strength. Isotonic contractions cause muscles to shorten and thicken and cause movement at a joint. Isotonic exercises help restore movement after an injury and relieve stiffness and pain. ROM exercises help to maintain flexibility and joint mobility and reduce stiffness. Active ROM exercises are done by the patient, whereas passive ROM exercises are done by a caregiver or therapist. For patients who have had a stroke or other trauma that affects movement, daily ROM exercises are critical to prevent joints from freezing up. Frozen joints have limited to no movement.

Electrical muscle stimulation

A transcutaneous electrical nerve stimulation (TENS) unit is used for pain relief (Figure 36.10). Electrodes are placed on the skin in specific locations. The adjustable low-voltage machine sends electrical current through disposable gel electrodes into the skin. The current stimulates specific nerves, producing a tingling or massaging sensation that reduces pain. TENS units have been used for passive exercise of muscles when a patient cannot exercise the extremity (e.g., due to injury or stroke). The electrical stimulation can prevent atrophy of normal muscles. TENS units are also used to treat the pain from muscle, joint, or other orthopedic conditions.