2022 Superficial Thermal Lecture

Paraffin Baths

• Disadvantages

– messy
– expensive to replace wax mixture
– danger of contamination
– cleaning paraffin bath tank can be difficult
– vigorous doses of heat can increase harmful

enzymatic activity for patients with rheumatoid
arthritis

However, paraffin baths can be messy, the wax mixture is expensive to
replace, and there can be a danger of contamination when replacing the
paraffin.
After completing a treatment, cleaning the paraffin bath tank can also be
time consuming and difficult.
Furthermore, when employing the immersion technique, the vigorous
doses of heat can increase harmful enzymatic activity for patients with
rheumatoid arthritis because the extremity is held in a dependent position
while heating is underway.

DISCARD PARAFFIN AFTER USE; DO NOT REPLACE IN
PARAFFIN BATH.

51

Paraffin Baths

• Application procedures:

– define patient’s problem and set intervention goal
– decide whether paraffin bath is appropriate modality
– outline the contraindications and precautions
– educate patient about procedure and address any

concerns
– ask patient to remove jewelry or clothing on area being

treated

The initial application procedures consist of
• defining the patient’s problem and
setting the intervention goal,
• deciding whether the paraffin bath is
the most appropriate modality,
• outlining the contraindications and
precautions relative to the patient,
• educating the patient about the
procedure and addressing any
concerns, and
• asking the patient to remove any
jewelry or clothing on the area that
will be treated.

52

Paraffin Baths

• Application procedures (cont.):

– check paraffin bath to ensure temperature does not
exceed 125oF

– after patient has washed and dried the area that will be
immersed, hold hand with fingers slightly spread and
dip hand into paraffin bath.

– remove hand and hold it over paraffin mixture until
hand stops dripping

– repeat this process 10 times, and after last dip cover
hand with plastic wrap and drape it with a towel

Check the paraffin bath to ensure the temperature does not exceed 125oF.
After the patient has washed and dried the
area that will be immersed, hold the
patient’s hand (with the fingers slightly
spread) and dip the hand into the paraffin
bath.
Immediately remove the hand and hold it
over the paraffin mixture until the hand
stops dripping.
Repeat this process ten times, and after the
last dip cover the hand with a plastic wrap
and drape it with a towel.

53

Paraffin Baths

• Application procedures (cont.):

– after setting treatment timer for 15-20 minutes, ask patient to
indicate immediately if paraffin feels too hot (such as a burning
sensation) or is uncomfortable

– patient’s hand will begin to feel cool following a short period of
intense warmth

– at the end of 5 minutes, check patient’s status and ask how
treatment felt

– skin will not be visible for inspection because of the opaque nature
of the wax

– at the end of the 20-minute treatment session, remove towel and
plastic wrap and discard paraffin

– when inspecting skin, treated area should appear slightly red and
be warm to the touch

After setting the treatment timer for 15-20 minutes, ask the patient to
indicate immediately if the paraffin feels too hot (such as a burning
sensation) or is uncomfortable.

Advise the patient that during the treatment, the hand will begin to feel
cool following a short period of intense warmth.

At the end of 5 minutes, check the patient’s status and ask how the
treatment felt.

• Note, though, the skin will not be visible for inspection because of
the opaque nature of the wax.

At the end of the 20-minute treatment session, remove the towel and
plastic wrap and discard the paraffin.

When inspecting the skin, the treated area should appear slightly red and
be warm to the touch.

54

Fluidotherapy

• Special chamber suspends finely ground cellulose
particles in warm air

• Circulating fine particles can provide heat,
massage therapy, and sensory stimulation
simultaneously

• Temperature is regulated to provide mild,
moderate, or vigorous doses of heat

• Air flow can be controlled to create environment
of oscillating pressure to decrease edema

Fluidotherapy involves utilizing a special chamber that suspends finely
ground cellulose particles in warm air.
When the fine particles circulate in the fluidotherapy unit, they will
simultaneously provide dry heat, massage therapy, and sensory stimulation
to the patient.
The temperature is regulated so the patient can receive either mild,
moderate, or vigorous doses of dry heat, and the air flow can be controlled
to create an environment of oscillating pressure to decrease edema.

55

56

Fluidotherapy

• Stimulation of sensory receptors result in counter irritation
of pain stimuli that decreases sensitivity created by
oscillating environment which will help reduce pain

• Treating hands at 115oF will result in significant increase
of blood flow and metabolic rate

• Analgesic effects can be obtained at lower temperatures
• Physiologic effects can be attained at higher temperatures,

including enhancement of tissue elasticity, reduction of
viscosity and improvement of joint mobility

When the sensory receptors are stimulated by the treatment, it will result
in a counter irritation of the pain stimuli and decrease the sensitivity
created by the oscillating environment, which will subsequently help
reduce the pain.
Furthermore, when the hands are treated at 115oF, it will result in a
significant increase of the blood flow and metabolic rate.
Analgesic effects can be obtained with lower temperatures, while
physiologic effects can be attained at high temperatures, including

• the enhancement of tissue elasticity,
• reduction of viscosity, and
• the improvement of joint mobility.

57

58

Fluidotherapy

• Advantages

– unit is easy to operate and move, and does not
require towels or plumbing fixtures

– heat can be evenly distributed over entire area
being treated, including when wound is properly
bandaged and covered with plastic

– adjustments to airflow will allow effective
intervention to treat hypertension

– PROM, AROM and AAROM are possible during
application

A fluidotherapy unit is easy to operate and move, and does require the use
of towels or plumbing fixtures.
Since the temperature is regulated and air is continuously moving, heat
can be evenly distributed over the entire area being treated, including
when a properly bandaged wound is covered with a plastic wrap.
The airflow can be adjusted (and interrupted up to 6 seconds), and is an
effective intervention modality to treat hypersensitivity.
Furthermore, the therapist is capable of providing passive range of motion,
joint mobilization and manipulation while the fluidotherapy is engaged.
It also allows the patient to be actively involved when performing active
and assisted range of motion.

59

Fluidotherapy

• Disadvantages

– only applicable to distal extremity
– hands must be in a dependent position
– treatment can be messy and become a safety issue
– unit is relatively expensive to purchase

While fluidotherapy is effective for treating hands and feet, it is not
practical for treating elbows or shoulders.
Also, the hands must be maintained in a dependent position when using
this type of modality.
The treatment process is generally messy and if the cellulose particles are
spilled on the floor, it will create a slippery surface that could become a
safety issue.
Lastly, a fluidotherapy unit is a relatively expensive piece of equipment to
purchase.

60

Fluidotherapy

• Application procedures:

– define patient’s problem and set intervention goal
– decide whether fluidotherapy is the most appropriate

modality
– preheat fluidotherapy unit to desired temperature to

achieve mild, moderate, or vigorous heating
– outline contraindications and precautions relative to the

patient
– educate patient about the procedure and answer

concerns
– ask patient to remove any jewelry or clothing on area

being treated

The initial application procedures consist of
• defining the patient’s problem and setting an intervention goal,
• deciding whether fluidotherapy is the most appropriate modality,
• preheating the fluidotherapy unit to the desired temperature to
achieve mild, moderate, or vigorous heating,
• outlining the contraindications and precautions relative to the
patient,
• educating the patient about the procedure and answering any
concerns, and
• asking the patient to remove any jewelry or clothing on the area
that will be treated.

61

Fluidotherapy

• Application procedures (cont.):

– Patient’s hands must be thoroughly washed and dried
– When treating a person with an open wound, a clean bandage must

be placed over the wound and covered with plastic bag that can be
properly secured
– Sleeve must be immobilized with Velcro straps so cellulose
materials cannot escape
– Before placing hand through the portal of a fluidotherapy machine,
check the controls to ensure the unit is turned off
– If active assisted range of motion is to perform, have the patient
place their unaffected hand in the second unit portal

The patient’s hands must be thoroughly washed and dried before
beginning the treatment.

When treating a person with an open wound, a clean bandage must be
placed over the wound and covered with a plastic bag that can be properly
secured.

Also, the sleeve must be immobilized with Velcro straps so the cellulose
materials will not escape.

Before placing a hand through the portal of a fluidotherapy machine,
check the controls to ensure the unit is off.

If active assisted range of motion will be performed, have the patient place
the unaffected hand in the portal of a second unit.

62

Fluidotherapy

• Application procedures (cont.):

– ensure the patient is in a comfortable position
– set the temperature gauge to the desired level
– turn machine on, adjust degree of air flow and agitation, and set

and start treatment timer for 20 minutes
– at the end of the 20-minute treatment session, undue the Velcro

straps and remove hands without spilling cellulose particles
– inspect the skin and note treated area should appear slightly red

and feel warm to the touch

Ensure the patient is in a comfortable position and set the temperature
gauge to the desired level.
When the fluidotherapy unit is turned on, adjust the degree of air flow
and agitation, and set and start the timer for 20 minutes.
At the end of the 20-minute treatment session, undue the Velcro straps
and remove the hands without spilling the cellulose particles.
Inspect the skin and note the treated area should appear slightly red and
feel warm to the touch.

63

Whirlpool Bath

• Hydrotherapy process that uses forced air to agitate water
in a tank to provide mild, moderate, or vigorous doses of
heat

• Achieves thermal or cryo results or attains mechanical
therapeutic effects:

– warm or cold water whirlpools evoke same local and systemic
responses as other modalities

– mechanical therapeutic effects are particularly useful for
wound care and edema control

• Water buoyancy can enhance exercise and can aid recently
healed fractures, inflammatory conditions, peripheral
vascular disease, and peripheral nerve injuries

A whirlpool bath is a hydrotherapy process that uses forced air to agitate
water in a tank to provide mild, moderate, or vigorous doses of heat.

Whirlpools are used to achieve thermal or cryo results or to attain
mechanical therapeutic effects, depending on the objective of the
application.

The use of either warm or cold water whirlpools will evoke the same
local and systemic responses as other modalities, whereas the
mechanical therapeutic effects are particularly useful for wound care (such
as cleaning wounds and debridement) and edema control.
Since water has a buoyant nature, it can also provide a gravity eliminated
environment to enhance exercise, and can aid recently healed fractures
(when stiffness and excessive dry skin occur), inflammatory conditions,
peripheral vascular disease, and peripheral nerve injuries.

64

Whirlpool Bath

• Advantages • Disadvantages

– allow observation of body – extremity held in dependent
segment being treated position

– permit specialized treatment – risk of cross contamination

– temperature and water – time consuming and messy
agitation can be controlled
– require large amounts of hot
– suitable for massaging soft water
tissue and improving strength

– AROM possible during
immersion

Whirlpool baths allow observation of the body segment being treated and
permit specialized treatment (such as debridement).

Since the temperature and water agitation can be controlled and the
patient’s extremity can freely move within the water, this modality is
suitable for massaging soft tissue and improving strength.

This active form of treatment will also allow the patient to be involved in
accomplishing the therapeutic goals.

However, the patient’s extremity must be placed in a dependent position
during the entire treatment session.

If there are multiple patients using the tub, this will cause an increase in
the risk of cross contamination.

This form of treatment is also time consuming, messy, and requires large
amounts of hot water.

65

Whirlpool Bath

• Application procedures:

– define patient’s problem and set intervention goal
– decide whether a whirlpool bath is the most appropriate

modality
– fill tub with water at the temperature level to meet

treatment goal
– outline contraindications and precautions relative to the

patient
– educate patient about the procedure and answer

concerns
– ask patient to remove any jewelry or clothing on area

being treated

The initial application procedures consist of
• defining the patient’s problem and setting an intervention goal,
• deciding whether a whirlpool bath is the most appropriate modality,
• filling the tub with water at the temperature level that will meet the
treatment goal,
• outlining the contraindications and precautions relative to the
patient,
• educating the patient about the procedure and answering any
concerns, and
• asking the patient to remove any jewelry or clothing on the area
that will be treated.

66

Whirlpool Bath

• Application procedures:

– check water temperature to ascertain it is set at 100o-104oF for
heating and 90-100 degrees F for open wounds

– comfortably position patient and submerge extremity in tank
– ensure fingers are not near the water agitation device
– after starting water agitator, adjust the speed and direction of water

flow
– set treatment timer for 20 minutes and stay with patient for entire

treatment session to monitor vital signs and subjective responses to
treatment
– at the end of the 20-minute treatment session, remove extremity
from water, dry it with a towel, and inspect treated area

Check the water temperature to ascertain it is set at 100o-104oF for heating
and 90-100 degrees F for open wounds.
Comfortably position the patient and submerge the extremity in the tank.
Also, ensure the fingers are not near the water agitation device.
After starting the water agitator, adjust the speed and direction of the water
flow.
Set the treatment timer for 20 minutes and stay with patient for the entire
session to monitor vital signs and subjective responses to the treatment.
At the end of the 20-minute treatment session, remove the extremity from
the water, dry it with a towel, and inspect the treated area.

67

Contrast Baths

• Involve immersing an extremity in
alternating tubs of hot and cold water:

– indicated for treatment and control of edema
– blood vessels within an edematous extremity

cycle between vasodilatation followed by
vasoconstriction
– promotes blood flow and helps with venous and
lymphatic return

Contrast baths involve immersing an extremity in alternating tubs of hot
and cold water for the treatment and control of edema.
This treatment modality will allow the blood vessels within an
edematous extremity to cycle between vasodilatation followed by
vasoconstriction.
This cycling causes a pumping action that promotes blood flow, which in
turn, helps with the venous and lymphatic return to decrease edema.

68

69

Contrast Baths

• Most frequently recommended treatment
rotation is a 3:1 or 4:1 rotation:

– extremity is held in hot water for 3 or 4 minutes
(between 105o to 110oF)

– Subsequently, extremity is immersed
immediately in cold water (between 50o to
60oF)

The most frequently recommended treatment rotation is a 3:1 or 4:1
rotation in which the extremity is held in hot water for 3 or 4 minutes at a
temperature level between 105o to 110oF.
Subsequently, the extremity is immediately immersed in cold water at a
temperature level between 50o to 60oF.

70

Contrast Baths

• Deciding which bath to end treatment will
depend on rationale for treatment and
overall treatment objectives:

– if desired effect of treatment is to achieve state
of vasoconstriction, then last bath will be in
cold water

– if state of vasodilatation or relaxation is desired,
then last bath will be in warm water

Deciding which bath to end the treatment will depend on the rationale for
the treatment and the overall treatment objectives.

• If the desired effect of the treatment is to achieve a state of
vasoconstriction, then the last bath will be in cold water.

• However, if a state of vasodilatation or relaxation is desired, then
the last bath will be in warm water.

71

Contrast Baths

• Indications for contrasting bath treatment:

– reduction of edema
– pain reduction
– impaired circulation

• If goal is to improve impaired circulation,
treatment procedures must be closely
observed

The general indications for a contrasting bath treatment include the
reduction of edema, pain reduction, and impaired circulation.
However, if the goal is to improve the impaired circulation, then the
treatment procedures must be closely observed.

72

Contrast Baths

• Contraindications include:

– treatment following acute injuries
– any hypersensitivity to cold

• Contraindications relative to cryotherapy
and thermotherapy also apply to this type of
modality

The contraindications for contrast baths include treatment following acute
injuries and any hypersensitivity to cold.
The contraindications relative to both cryotherapy and thermotherapy also
apply to this type of modality.

73

Case Study

MR is a 38 y/o female patient who is employed as a clerk. Her
occupation responsibilities include entering computer data and filing.
She has also been remodeling her house and one weekend painted the
entire family room and kitchen. She returned to work on Monday, but
by Tuesday afternoon she felt pain and stiffness in her dominant right
shoulder. She was referred to occupational therapy and was diagnosed
with acute bursitis in her right shoulder. The diagnosis indicated she
has localized pain in the anterior compartment, the muscle strength is
grossly 5/5, she can display the full passive ROM and there is marked
guarding of the extremity when is taken above 100 degrees. The
patient also indicated the pain becomes aggravated during filing and
any activity that requires elevation of her arms above 90 degrees. She
reported feeling better while taking a hot shower when the water runs
down her shoulder.

MR is a 38 year old female patient who is employed as a clerk. Her
occupation responsibilities include entering computer data and filing. She
has also been remodeling her house and one weekend painted the entire
family room and kitchen. She returned to work on Monday, but by
Tuesday afternoon she felt pain and stiffness in her dominant right
shoulder. She was referred to occupational therapy and was diagnosed
with acute bursitis in her right shoulder. The diagnosis indicated she has
localized pain in the anterior compartment, the muscle strength is grossly
5/5, she can display the full passive range of motion, and there is marked
guarding of the extremity when taken above 100 degrees. The patient also
indicated the pain becomes aggravated during filing and any activity that
requires elevation of her arms above 90 degrees. However, she reported
feeling better while taking a hot shower when the water runs down her
shoulder.

74

Analysis of Clinical Findings

This patient manifests localized pain and
functional impairment of the upper extremity
consistent with an overuse syndrome.
Furthermore, she manifests limitation of active
movement and localized pain in the anterior
compartment of the right shoulder joint. The
muscle strength is within functional limits, but the
range of motion is limited due to the pain and
secondary guarding.

This patient manifests localized pain and functional impairment of the
upper extremity consistent with an overuse syndrome.
Furthermore, she manifests limitation of active movement and localized
pain in the anterior compartment of the right shoulder joint.
However, the muscle strength is within functional limits, but the range of
motion is limited due to the pain and secondary guarding.

75

Proposed Goals of Treatment

At this time, the proposed goals of treatment
include to decrease the pain, improve the
range of motion, and establish functional,
pain-free use of the right upper extremity.

At this time, the proposed goals of treatment include to
• decrease the pain,
• improve the range of motion, and
• establish functional, pain-free use of the right upper extremity.

76

Assessment Regarding
Appropriateness of Thermotherapy as

Optimal Treatment

This patient’s condition is likely due to an acute overuse
syndrome, similar to post-exercise induced stiffness.
There is no known history of shoulder impingement
syndrome and no prior reports of pain or discomfort with
any of her premorbid activities. Since the patient reported
subjective relief from the pain following a hot shower,
superficial heat in the form of a hot pack should be the
initial approach. Thermotherapy may be indicated for this
patient since it can decrease pain, stiffness, and soft tissue
shortening. Also, there are no known contraindications if
thermotherapy is given to this patient.

This patient’s condition is likely due to an acute overuse syndrome,
similar to post-exercise induced stiffness.

There is no known history of shoulder impingement syndrome and no
prior reports of pain or discomfort with any of her premorbid activities.

Since the patient reported subjective relief from the pain following a hot
shower, superficial heat in the form of a hot pack should be the initial
approach.

Thermotherapy may be indicated for this patient since it can decrease
pain, stiffness, and soft tissue shortening.

Also, there are no known contraindications if thermotherapy is given to
this patient.

77

Proposed Treatment Plan and
Rationale

Using a deep or superficial heating agent would be
appropriate for this patient. Although a deep heating agent
may be initially used to treat this condition, superficial
heat should be attempted first for approximately 20 minutes
since the patient reported relief from the shower. The
temperature and skin condition should also be monitored to
avoid burning the patient. To optimize the benefit of
increased soft tissue extensibility, engagement in active
and/or passive stretching and occupations should be
performed immediately following the application of the
thermal agent.

Using a deep or superficial heating agent would be appropriate for this
patient.
Although a deep heating agent may be initially used to treat this condition,
superficial heat should be attempted first for approximately 20 minutes
since the patient reported relief from the shower.
The temperature and skin condition should also be monitored to avoid
burning the patient.
To optimize the benefit of increased soft tissue extensibility, engagement
in active and/or passive stretching and occupations should be performed
immediately following the application of the thermal agent.

78