WATER AS THERAPEUTIC AGENT



TABLE OF CONTENTS

UNIT 1: WATER AS THERAPEUTIC AGENT

1.1. Physical Principles

1. Buoyancy

2. Pressure

3. Cohesion

4. Viscosity

1.2 Water temperature:

1.3.Methods of heat transfer

1. Key Points

2. Conduction

3. Convection

4. Radiation

5. Evaporation

UNIT 2: BIOPHYSIOLOGICAL EFFECT OF WATER

• Thermal Effects

• Cold Water Effects

• Hot Water Effects

• Clinical Effects of Mild General Body Heating

• Psychological Effects

• Table 1: General classification of temperature- ranges

• Factors that affect the results of hydrotherapy

•

UNIT 3: GENERAL CONSIDERATIONS TO HYDROTHERAPY

• Definition

• Value of activity in water

• Adjustment to water

o Breathing control

o Relaxation

o Head control

o Balance control

o Movement

o Body image and spatial relationship

• Environment for hydrotherapy

o Pool Size

o Pool Depth

• Indications for underwater exercises

• Methods of application of Hydrotherapy

• Treatment of specific conditions

UNIT 4 HYDROCOLLATOR PACKS

1. Introduction

2. Biological effects

3. Indications

4. Contraindications

5. Advantages and Disadvantages of application

6. Method of Application

7. Care of the Apparatus

8. Dangers and Precautions

9. Hot compresses: Method of application and indications.

INTRODUCTION

Historical Perspective

Hydro- and hydrothermal therapy are traditional methods of treatment that have been used for the treatment of disease and injury by many cultures, including those of ancient Rome, China, and Japan. Water therapy has been around for centuries. The ancient Greeks took therapeutic baths. Water is an important ingredient in the traditional Chinese and Native American healing systems.

UNIT 1:

WATER AS THERAPEUTIC AGENT

Hydrotherapy is one of the eldest therapeutic methods for managing physical dysfunctions.

It has been advocated for the treatment of joint stiffness, painful scars, adhesions, arthritis and as warm-up to assist with exercise.

Water therapy is used for the effects on body tissues of heating, cooling, debridement, pain relief and relaxation of muscles.

When treatment is not well planned or well executed, it can have adverse side effects primarily on the cardiovascular system.

Hydrotherapy achieves its desired effects through the physical properties of water, temperature and agitation.

A basic understanding of these physical principles, normal physiology, and pathology involved serves as a foundation for the decision to use hydrotherapy in the treatment of specific dysfunction.

1.1. PHYSICAL PRINCIPLES OF WATER

Water has the inherent following forces which play a role in the effects produced on the body from hydrotherapy:

5. Buoyancy

6. Pressure

7. Cohesion

8. Viscosity

1. Buoyancy:

The most important principle is Archimede’s principle of buoyancy.

This principle states that a body immersed in a liquid experiences an

upward force equal to the weight of the displaced liquid.

Thus, the body will appear to weigh less in water than in air.

Buoyancy may be affected by:

a. The postural alignment.

b. The surface area immersed.

c. The weight of the bones in relationship to muscle and fat.

d. The vital capacity.

The buoyancy of the water can be used to assist with exercise of the extremities and to minimize stress of joints and muscles. Work can be done in the opposite direction, against the assist of buoyancy, so that resistance to motion can be exerted.

In addition, by varying the speed of exercise in water, the difficulty of exercise may be graded or changed.

o The principle of relative density is used to provide support of the body and its limb in the water.

o The specific gravity is the ratio of the weight of a volume of substance to the weight of an equal volume of water. The specific gravity of a body is approximately 0.974. Objects with a specific gravity less than 1.0 will float in water. The specific gravity of a body can be advantageous to exercise in water.

2. Pressure:

Water exerts a perpendicular pressure against the surface of the body.

This hydrostatic pressure is the ratio of the magnitude of the force exerted by the fluid per body surface area.

This pressure is dependent on the depth of the submerged part and the density of the liquid. Hydrostatic pressure increases as depth and density of the liquid increase.

Therefore, motion is performed more easily near the surface of the water than at greater depths.

3. Cohesion:

Water molecules are cohesive; they have the tendency to attract each other. This results in an increase in viscosity of the medium, as compared to that of air, and an increase in resistance to range of motion.

4. Viscosity:

Viscosity is internal friction, the property of liquids that resist relative motion within it. The greater the speed of the liquid, the higher it’s viscosity.

Resistance to motion is also dependent on the shape of the body.

The more streamlined the body or object, the less force is required to move it through the water.

The larger or more spread out the object moving through water, the greater the resistance to motion.

As discussed later, viscosity and pressure will play a role in turbulence created by the whirlpool agitation.

1.2 Water temperature:

As seen in the previous points, water is applied for its thermal effect. We have to be aware of the temperature ranges. Water at 92F to 97F (33.5 to 35.5C) gives the sensation of being natural (neither hot nor cold).

Table 1: General classification of temperature – ranges

|Very cold |34° – 55°F |1° – 13°C |

|Cold |55° – 65°F |13° – 18°C |

|Cool |65° – 80°F |18° – 27°C |

|Tepid |80° – 92°F |27° – 33.5°C |

|Neutral |92° – 96°F |33.5° – 35.5°C |

|Warm |96 °– 98°F |35.5° – 36.5°C |

|Hot |98° – 104°F |36.5° – 40°C |

|Very hot |104° – 115°F |40 °– 46°C |

Factors that affect the results of hydrotherapy:

• Water temperature

• Difference between the skin and water temperature

• Methods of application

• Suddenness of application

• The extend of the surface covered

• The duration of treatment

• The frequency of treatment

• The weight, age, and general condition of the patient.

1.3.Methods of heat transfer

1. Key Points in this Unit:

• Conductive heating: is the transfer of heat between two objects in contact, and at different temperatures, heat being transferred by conduction from the warmer object to the cooler one.

• Convective heating: is the transfer of heat energy by means of convection currents which arise due to temperature and density differences in various parts of a fluid.

• Specific heat: of a substance is the heat required per unit of mass to change the temperature one degree Celcius.

It is expressed as a ratio of the amounts of heat required to raise the temperature of equal masses of the substance and water by the same amount. The value for water is taken as one.

• Thermal conductivity: is the ability of a tissue to absorb heat and conduct in across the tissue.

• Hydrocollator: is an automatic heating unit which holds a supply of steam packs heated in water at a constant temperature.

• Moist heat: is the production of heat by a moist source.

• Parrafin wax bath: is an automatic heating unit which holds a low melting point at a steady temperature, ready for use.

Hydrotherapy is performed in water tanks of varying sizes and shapes. Tanks used for partial body immersion (of one or two extremities) are termed whirlpools.

Tanks used for full body immersion are referred to as Hubbard tanks, walking tanks or hydrotherapeutic exercise tanks or pools.

When the body is immersed, thermal energy is exchanged by water in the tank by two methods: conduction and convection.

Two other methods of transferring heat are also radiation and evaporation in other techniques of hydrotherapy.

1. Heat Exchange by Conduction:

As heat is a form of energy motion, the transfer of heat on a molecular scale is affected by the transfer of kinetic energy during the collision of molecules.

Conduction is the diffusion of this energy from one body to another.

Conduction is an exchange of thermal energy in which there is physical contact between two surfaces. If the water temperature is higher than the skin temperature, heat will be conducted to the skin and the temperature will rise.

When an object is heated by a source in contact with it, the speed at which the heat will flow will and cause a rise in temperature will depend upon the thermal conductivity of the source and substance.

The thermal conductivity of water is greater than that of fat.

Tissues with high water content will conduct faster than tissues with low water content.

The specific heat of the tissue will also govern the amount of heat needed to raise temperature by any particular amount. Fat has a specific heat of only 0.6 and can therefore be heated with less expenditure of energy than of water (specific heat = 1.0).

Since fat acts more as an insulator, than as a conductor, it has a tendency to hold heat in or to keep it out.

This point is important for two reasons:

• The effect of superficial heating by conduction will be lessened as the body fat composition increases.

• Higher body fat content compromises the body’s ability to dissipate heat, which may cause an increase in body-core temperature to dangerous levels.

With the obese person, therefore, superficial heating with the whirlpool may not achieve the intended effects. Caution must be taken when a large body surface area is immersed; the person may not be able to dissipate internal heat and maintain a proper core temperature. This may present a dangerous situation, requiring other methods of heat loss, such as evaporation and convection, to work over time causing dehydration and increased cardiac output. A particular patient’s medical condition may not tolerate this situation, such as a patient with cardiac or peripheral vascular diseases.

Sources of conductive heating include:

• Solids- mud and peat packs, and electric heating pads;

• Liquids- thermal water baths, and contrast baths, hot packs, paraffin wax.

• Gasses- hot air, hot vapor baths.

Heat is transmitted by conduction and some convection.

Most commonly used modalities for therapeutic purposes are hydrocollator packs and paraffin wax baths.

2. Heat Transfer by Convection

Convection which occurs when a portion of the fluid moves from one place to another, is a more rapid process of thermal energy exchange than conduction.

Energy transfer by convection occurs when the patient is moving in the water or when the water swirls across the skin surface. Convection plays an important role in heating or cooling tissues, as well as in dissipating or retaining body heat.

Convection occurs between the core and the shell of the body. Surface body heat can be carried by the venous blood toward the core, thus potentially increasing the core temperature.

Conversely, convection will help with heat dissipation by carrying heat away from areas of the body that are being heated. This method of heat transfer is compromised when the patient has cardiovascular or peripheral vascular disease. In this case, heating an entire extremity or full body may create dangerous overheating because the extremity or body is unable to dissipate heat from the treated area to maintain tissue temperature at safe levels.

These two methods of heat transfer are used to transport heat in either direction in the body.

Two other methods of heat transfer, radiation and evaporation, help to dissipate heat from the body during or following a hydrotherapy treatment.

3. Heat Transfer by Evaporation

The other heat transfer mechanism used to dissipate heat is evaporation. No temperature gradient is necessary.

Evaporation occurs through the loss of fluid from sweating and by the pulmonary system during exhalation.

Any disturbance with the autonomic nervous system or pulmonary system’s functions may interfere with loss of heat by evaporation.

Therefore, when administering hydrotherapy, sufficient body surface must be exposed to the air to allow heat los. Otherwise water temperatures must be kept below a body temperature between 33.3°C and 36.6°C.

Heat loss is affected by:

• The medical condition of the patient and his/her ability to cope with heat.

• The environmental factors of humidity and temperature.

If either humidity and /or ambient room temperature are too high, the body will have great difficulty with heat loss. On the other hand, should the ambient temperature be too low and the area dry, heat loss may occur to a greater extent than needed causing a chill.

Therefore, muscle and joint stiffness secondary to the reduction in peripheral circulation could occur. Strong consideration should always be given to the design and environment of the hydrotherapy area.

UNIT 2: BIOPHYSIOLOGICAL EFFECT OF WATER

Thermal Effects

One of the principal reasons for using hydrotherapy is to gain the therapeutic value of heat or cold.

As with hydrotherapy, a larger body surface is usually immersed in water, the exposure of the body to varying temperatures will have not only a local effect but also systemic effects on the cardiovascular and other organs systems.

The greater the difference in temperature between the water and skin, the more intense the reaction is.

• Cold application to the whole body decreases the heart rate and lengthens diastole. The tone of the cardiac muscle is enhanced, and blood pressure is raised, as a result of peripheral vasoconstriction. The increase in peripheral resistance requires the heart to work harder to maintain adequate blood flow to the periphery.

• The application of heat to the entire body will cause an initial increase in blood pressure, followed by a decrease in blood pressure as a result of vasodilatation. The initial rise in blood pressure may be quite marked and prolonged if the temperature of the bath is very high, above 40°C.

• Respiratory rate will increase with the application of heat or cold, although the increase might be less marked with the application of heat.

• In addition sweating will increase; the amount is dependent on the temperature, the size of body surface exposed, and the length of treatment.

• Whether the use of hydrotherapy bath increases diuresis remains controversial, but diuresis is affected by the hydrostatic pressure, which increases with the depth of immersion.

Cold Water Effects:

• Short application of cold water has a stimulating effect and results in peripheral vasoconstriction, pallor of the skin, chilliness, increased muscle tone, increased pulse rate, increased respiratory rate, rise in blood pressure and involuntary shivering, which in turn is responsible for more heat production in the body.

• Removal from water results in peripheral vasodilatation, redness of the skin, a feeling of warmth, a decrease of blood pressure, relaxation and a decrease in pulse and respiratory rate.

Hot Water Effects:

Local application of mild heat has a sedative effect upon irritating conditions and in cramps and spasms. Heat applied to a large portion of the body in sufficient dosage results in an increase in body temperature and general physiologic changes.

• There is an increase of the circulatory rate and metabolism.

• A rise in blood volume and oxygen consumption and a change in the pH of urine, blood and sweat to the alkaline side.

Clinical Effects of Mild General Body Heating:

• Increased heat elimination and perspiration.

• Increased circulation.

• A rise of the pulse rate in the ratio of about 10 beats for every degree Fahrenheit, just as in fever.

• A lowering of blood pressure in contrast to the effects of cold.

• Increased elimination through the kidneys.

• Increased respiration.

• Loss of water, salt, urea and other nitrogenous substances with a relative excess of alkali remaining in the blood and the tissues.

• A temporary loss of body weight.

• General nervous sensibility is markedly lessened.

Psychological Effects:

The smallest amount of voluntary motion which might not be possible in air helps the patient retain a “body image” of movement and gives him/her the hope of one day moving the part without the help of water.

UNIT 3: GENERAL CONSIDERATIONS TO HYDROTHERAPY

Definition

Hydrotherapy is the external application of water for therapeutic purposes. It may be applied in its solid (ice), liquid or vapor (steam) state.

Value of activity in water

Swimming is an essential part of everybody’s physical education and it is suggested that the value of swimming is for survival, fitness and fun.

For the disabled subject, we hope to integrate him to an as possible normal life, with the abilities to survive, achieve maximum fitness and enjoy the element of water.

Adjustment to water

The adjustment to the element of water is of prime importance:

This can be achieved through the followings:

1. Breathing control

Good breathing control is essential for all activities in water including swimming. It is frightening to inhale water, which can be avoided by encouraging blowing or breathing out. Blowing is also a pre-requisite for head control, since it helps to bring the head forward and assist in creating forward rotation around the center of buoyancy.

2. Relaxation

Relaxation or relief of tension is essential for the activity in water. Relaxation is achieved through:

a. Support, given to the body by the buoyancy.

b. Weightlessness, experienced by the body when placed in water.

c. Warmth of water.

3. Head Control

Development of head control forms the basis for development of all functions. Where the head goes, the body follows. If this is true on land, then it is equally true in water.

4. Balance control

Balance control is acquired through learning how to cope with the body shape and rotational movements that occur as a result of altered shape and by adjustment to the effect of buoyancy.

5. Movement

Movement in water as well as balance and stability is important. It includes the change from positions of standing, sitting, kneeling and lying, to walk forwards, backwards and sideways in water.

6. Body image and spatial relationship

They can be improved in water through learning body dimensions and the position of the limbs in space as well as in relation with the rest of the body.

Environment for Hydrotherapy:

The importance of the environment, in which the patient will participate in water activity, will aid to success. The less elaborate the design, the more useful it becomes in therapy and recreation. The environment comprises:

• Temperature:

On taking disabled subjects into water, both air and water temperature should be between 30°C and 34°C. If the water is too warm, it proves to be exhaustive and uncomfortable. However, if the water is too cold, inhibition of movement may occur. Air temperature has to be lower than the water temperature to allow gentle cooling.

• Pool Size:

In the hydrotherapy departments, sizes of pools may vary. Where there will be adults, who will use it in a group activity, a large pool, deep at one end, will be the best choice.

In orthopedic hospitals, a large but shallower pool is indicated. Where the patient population is limited to children, the pool should be small and shallow.

• Pool Depth:

The optimum depth of a hydrotherapy pool for the majority of treatments will equal to the waist or mid-chest height. It is suggested that a depth that varies between 1.00 and 1.20 meter will be suitable for most physical therapists. It is usually considered that some areas of the pool should be provided with depths less than and greater than this range, for children or for walking re-education.

These varying depths are accomplished by:

- sloping floor

- stepping floor

- the combination of both.

Indications of underwater exercises

- Muscle weakness

- Amputation

- Joint injuries

- Cerebral Palsy

- Burns

- Juvenile rheumatoid arthritis.

UNIT 4: Common techniques

A number of techniques are available under the general heading of hydrotherapy. These include: Hydrocollator, stream baths(foot, face ,neck ,thigh etc.), sauna, hot & cold compresses, moist sheet pack etc

HYDROCOLLATOR PACKS

1. Introduction:

The use of moist heat as a therapeutic agent is one of the oldest forms of medicine. Today we have efficient automatic units producing a uniform and constant temperature to heat steam packs.

They provide physical therapists with a constant left supply of ready–to–use heated packs. The heating unit is called a hydrocollator unit.

The hydrocollator unit is a stainless steel tank in which silica gel packs are heated. The capacities of the machines vary, and all units have insulated bases, the larger machines being insulated with fiberglass.

The units contain a wire rack which acts as divider for the packs and prevents contact of packs with the bottom of the tank.

The heater is thermostatically controlled and maintains water in the unit at a temperature between 76°C and 80°C. It can be left on continuously as long as there is enough water in the tank.

A hydrocollator pack is a fabric envelope containing silica gel. The main property of the gel is its capability to absorb many times its own volume of water and when heated, to give moist heat for 30 to 40 minutes. The packs are heated in a hydrocollator unit.

Packs come in various sizes and shapes. They are designed to fit nearly any body contour and are used repeatedly, being returned to hot water after each use.

A special collar pattern pack for the neck is usually available.

The packs are wrapped in:

a. Turkish towels

b. Special terry cloth blankets. ( absorbent)

c. Large packs may be wrapped in bath blankets.

The packs last about six months. When they begin to wear out the filler leaks out and makes the water cloudy; they should then be replaced.

Hydrocollator packs are used to give gentle moist heat to superficial regions of the body, mainly for the relaxation of pain and muscle spasms in superficial areas.

The part selected to be treated must be able to tolerate the pressure of the pack (approximately 500 to 800 grams) and to tolerate a 7° C to 10°C rise in temperature.

It is also necessary to ensure that the circulation can dissipate heat and that skin sensation responses to thermal differences are normal as it is easy to produce a burn.

The pack retains its heat for 30 minutes but after 10 minutes, the patient may regard the pack as cool and comfortable. Nevertheless, the rise in temperature of the region under pack averages 5°C.

The pack is applied to the body after being wrapped adequately in toweling or blankets. Care must be taken to have a layer of toweling and to avoid excessive pressure by weight being placed on bony points.

2. Biological Effects of Hydrocollator Packs

• Heat production: the effects of hydrocollator packs on the tissues is due mainly to heat generated, and is subject to the quantity and depth of penetration of the long infrared rays emitted from the pack.

When infrared is absorbed by tissues it produces heat. The penetration of the rays is no more than 0.5 to 1.00 mm deep.

The conduction depth is governed by the properties of the underlying fat, muscle, connective tissue and bone.

• Temperature Elevation: will depend upon the patency of the circulation and sensation, and the ability of the tissues to dissipate heat. Bone and fat will impede heat distribution; fatty tissues having a low specific will heat rapidly and will cause heat conduction away from the site.

Temperature rise takes place if the heat generated exceeds the rate at which the tissues can dissipate heat.

• Skin Tolerance: to heat is 44°C. Lower temperatures, such as 42°C for over two hours can cause a burn and a temperature of 44°C over 30 minutes can cause a burn. Temperatures of over 45°C over 5 to 10 minutes will cause a burn. Therefore a safe but effective application of heat is 44°C for 20 to 30 minutes.

• Thermal gradient in the tissues: Accurate assessment of temperature rises in subcutaneous tissues and muscles are not possible but a rough gauge has shown that hydrocollator packs have the following characteristics.

Skin temperature:

o Within 7 minutes there is a maximum 7°C to 8°C rise in temperature and then a drop of about 2°C over the remainder of the 20 to 30 minutes application period.

o Within 60 minutes =after treatment, the temperature returns to normal, a rapid drop occurring during the first 15 minutes after treatment.

Subcutaneous tissue and muscles temperature:

o In the areas of tissue where there is no obstruction by fat or bone, the subcutaneous tissues show a rise of about 3°C maximally in about 20 minutes which then disappears in about one hour, the maximum drop being after 15 minutes.

o In muscles there is an increase of about 1°C to 2°C maximally after 30 minutes, and then follows the same drop in temperature pattern as skin and subcutaneous tissue.

Hyperemia: There is an increased vasodilatation of the main venous channels in the skin through the opening of the arteriovenous anastomosis, by-passing the capillaries, since the main function of skin circulation is heat regulation. There is some increase in the flow of nutrients, antibodies, leukocytes, and oxygen to the tissues.

• Skin blood flow increases more than twofold, and remains at a constant level for about 15 minutes. This is due to the release of histamine-like substances and bradykinin producing vasodilatation of the capillaries. The local reddening occurs after a 20 minutes application of the packs. Blood flow to the joints is increased reflexively, and blood flow in distal muscles may be increased more than in proximal muscles.

• Increased vasodilatation of the superficial fascia and muscles is by heat conduction from the skin.

• Heat acts directly on muscle capillaries and directly on arterioles with reflex vasodilatation. The quantity of heat generated is minimal compared with that produced by heat and exercise. Muscle circulation can be increased effectively only by exercise. Recent experiments have shown that, following hot pack application and exercise, there is a total increase of blood flow, both in skin and muscle circulation, to about twice the amount that appears in exercise only, and the harder and longer the exercise, the longer-lasting is the muscle hyperaemia achieved.

• The amount of muscle blood flow increase is greater than that achieved by heat alone. So for moderate increase of blood flow to muscle, heat is not necessary.

Sedative Effects: Moist heat is a safe analgesic and muscle relaxant. There are two mechanisms by which moist heat is thought to produce these effects.

a) Muscle Spindle:

The mechanism governing relief of muscle spasm is poorly understood. It is thought to be due to a decrease of gamma fiber activity, thereby decreasing muscle spindle activity via the direct effect of heat on the skin receptors. A quick warming of the spindles causes a temporary, complete inhibition of the firing of the spindles. The central proprioceptive mechanisms may also be affected by the reflex action of heat, since raising the body temperature causes decreased gamma activity.

b) Small myelinated “c” nerve fibers:

Heat reduces the conduction velocity of the “c” nerve fibers. There are different theories of the mechanism underlying the relief of pain by heat. There is thought to be some alteration in the thermal threshold of pain. Disease or injury is said to alter the thermal threshold of pain. Heat alters the temperature of the painful part, thus the pain threshold alters to new thermal limits. On the other hand, metabolic, circulatory, tissue tension alterations and the counter-irritant effect of heat, also play important parts in relieving pain.

Metabolic effects will be governed by the rate of rise, the amount of rise and subsequent fall in temperature. There is some increase in tissue metabolism, and change in rate of enzymatic activity. Hot packs over two or three areas may cause a temporary increase in sweating, dehydration and a decrease in blood pressure.

Indications for Hydrocollator Packs

1. Pain and muscle spasm:

The moist heat of the hydrocollator pack can relieve pain and muscle spasm in superficial regions. It is thought that the quick rise in temperature and alteration of the temperature of the painful area by 2° to 5°C causes reduction of nerve conduction velocity of the pain nerve fibers and raises the threshold of pain . The rise in temperature also causes an increased circulation which then removes pain metabolites and thus breaks down the vicious cycle of pain and muscle spasm. The sudden rise in temperature can also create a counter-irritant effect, and thus cause a temporary relief of pain.

The rise of temperature lasts only for about 20 to 30 minutes. If the effect of heat on pain and muscle spasm is to be utilized, the techniques of physiotherapy needed to restore range of joint movement and muscle strength must be applied immediately after the heat has been administered.

2. Inflammation:

In cases of mild inflammation, temperature elevation of 2° to 5°C will cause an increase in phagocytosis and aid in abortion of exudates.

It has been used post-operatively for the healing of wounds following abdominal surgery, when there has been delayed healing with no infection, caused by mild haematomas or inflammation.

3. Oedema:

Oedematous areas over a large section of an extremity, in chronic stages, can be treated with hot pack in elevation to help absorption of the exudates. If the exhudates is excessive, other physical agents are more profitably utilized. The physiological mechanisms that occur are due to the increased permeability of cell membranes which cause the flow of fluid from the tissue spaces to the venous and lymphatic vessels. In oedematous areas the reverse vascular response occurs, as there is alteration of osmotic and hydrostatic pressures of the circulatory vessels.

4. Adhesions:

Hot packs in conjunction with other physical measures such as mobilization techniques, exercises and other measures will help to stretch adhesions and contractures tissues. The raised temperature of the collagen will make it easier to stretch the adhesions. Again this is only true if the adhesions are placed superficially and are not tenacious.

Contra-indications for Hydrocollator Packs:

1. Impaired Skin Sensation:

Impaired skin sensation will be determined by a hot/cold skin test. Some dermatological conditions are exacerbated by moist heat, such as eczema in the lower leg, athlete’s foot in between the toes and severance on the back. Any dermatological condition which appears after treatment must be reported.

2. Circulatory dysfunction:

Patients with severe varicose veins, deep vein thrombosis and arterial disease must not have any heat applied directly over the part affected by circulatory disease, particularly in the limbs.

2. Analgesic drugs:

If patients are under strong narcotics for pain, the time and dosage of the drugs must e ascertained. Heat is not administered immediately after intake of drugs, since pain tolerance to heat is impaired.

3. Infections and open wounds:

Heat will increase the infective activity.

4. Cancer and Tuberculosis:

In the area to be treated, heat will by increasing the metabolic rate, may increase the rate of growth and spread of the disease.

5. Gross Oedema:

In cases of gross oedema with a very thin and delicate skin covering the area, the skin may be damaged by the pressure of the pack and the heat may tend to increase the oedema.

6. Lack of Comprehension:

Patients who cannot understand the nature of the treatment and comprehend the potential dangers, for example, children, very old patients, other nationalities due their different language.

7. Deep X-Ray Therapy:

Deep X-Ray therapy within three months prior to treatment decreases blood flow in the area and may cause impaired skin sensation.

8. Liniment: may cause hypersensitivity to heat, if applied recently. The patient should be asked to apply the liniment after a heat treatment.

5. Advantages and Disadvantages:

Advantages:

• A hydrocollator pack is easy to apply; it saves time for personnel and is efficient in heat conduction depending on the area treated.

• The packs are of various sizes which fit most clinical needs.

• Moist heat has a more sedative effect than dry heat.

• Maximal temperatures are more uniform than in electrically-heated pads.

• The patient does not need much handling. The pads can be laid out ready for the patient to place on the affected part.

Disadvantages:

• A hydrocollator pack is not easily applied around shoulders and hips. It is somewhat heavy and should not be used on extremely sensitive patients, since it can create discomfort.

• Sometimes moist packs have a tendency to cause a skin rash.

6.Technique of Application of Hydrocollator Packs:

• Remove the pads and fill the tank three-quarters full of water. The water level should be kept slightly over the top of the pads at all times. This avoids the burning out of the heating element or scorching of the packs.

• Hold each pack by its loop so that its rectangular sections are horizontal and shake gently to distribute the dry gel evenly. Place the pack so that the rectangular section faces vertically to permit the loops to stick out of the water.

• Check that the thermostat is at 76°C to 80°C. Switch on the machine. As it takes approximately 2 hours to heat, the unit can be left plugged in for any length of time, provided the water level is maintained.

• Check that the room temperature is 21°C to 23°C.

• Position the patient with the part to be treated relaxed and fully supported in a comfortable position, pain-free and accessible for pack application and maintenance.

• Inspect the area to be treated for abrasions, cuts, wounds, scars, oedema and any circulatory dysfunctions.

• Test for hot and cold sensations.

• Do not expose the patient unnecessarily. Wrap the rest of the body in order to maintain normal uniform temperature, since a change in body temperature will alter the physiological effects of the hot packs.

• Explain to the patient the degree of warmth to be expected, the treatment duration and the purpose of the treatment.

• Ask the patient to inform you about any pain, discomfort or burning sensation if felt during the treatment.

• Remove the selected pack, holding it by the loops, and place it on a bath towel. Fold another towel into a 4 to 6 layers and place it over the pack. Wrap the whole pack up with the bottom towel. The temperature of the wrapped pack should not exceed the 44 °C skin tolerance. The hydrocollator pack when withdrawn from the machine should be at 70°C to 80°C. Higher temperatures cause discomfort.

• Place the pack gently with the folded towel side on the affected part. Check that the pack weight is not occluding circulation, particularly over bony areas.

• Treatment duration is usually 20 to 30 minutes. In case of severe pain and muscle spasms as in polyneuritis, the duration could be increased from 30 to 45 minutes, but the pack must be renewed after 20 minutes.

• Treatment must be given daily, particularly for the first course of treatment. The duration and frequency will be based on the acute, subacute or chronic clinical features of the case. Subsequent courses of treatment will be based on the progress of the patient in relation to the pathology of the condition, and the assessed results of the therapy.

• Remove the pack leaving the bottom towel in place. Return pack to the machine. Dry the treated area and inspect any signs of a burn of exacerbation of symptoms.

• Proceed with other treatments as indicated.

7. Care of the Apparatus

The unit should be cleaned periodically (every month) with a good metal cleaner after removing the packs. If left out for an extended period of time (especially in summer) the packs are likely to become mildewed. Cloudiness of the tank water is due to a slight leakage of the filter substance from the packs. This is not harmful and does not affect the packs or units in any way. The water level should be kept up to, or slightly over, the top of the packs at all times.

8. Dangers and Precautions:

1. Burns:

A bright red patch may indicate the possibility of a burn, with blistering to follow. Burns could be caused by any of the following factors:

a. Insufficient toweling between the pack and the skin surface. Part of the pack could have escaped out of the wrapping. Ensure there is a minimum of six layers of towels well wrapped around the pack.

b. The temperature of the pack could be too high; check the thermostat of the machine.

c. Impaired skin sensation, particularly in elderly patients, who have fewer glomera to regulate that dissipation, or in patients who have a peripheral neuropathy; or if the skin sensation test was performed inaccurately.

d. Impaired circulation due to circulatory disease, which was not detected from the case history or interview.

e. Hypersensitive skin from recent use of liniments or deep X-ray therapy.

2. Dehydration:

If two or more areas or one large area have been heated, excessive sweating may produce dehydration. A drink of water may help.

Hot Compresses:

Hot local compresses are primarily for home use and are not practical use. The main principles of heating by application of hydrocollator packs apply: heat by conduction, moist heat, and minimal penetration.

There is greater heat loss than with hydrocollator packs, and therefore the compresses have to be changed constantly.

Technique of Application:

a. Preparation of the equipment:

i. Turkish towels, strips of woolen blanket or any absorbent material

ii. Hot water at a temperature of 40 to 42C or Hot towel machine or microwave oven

iii. Plastic/ rubber sheet

iv. Timer.

b. Position the patient in a comfortable position with the part to be treated fully supported.

c. Check the skin area to be treated.

d. Place a large towel in a basin with the free endings hanging out. Place a smaller towel inside the large towel. Pour hot water on to the towel and wring them out.

e. Make sure the towels are thoroughly wet.

f. Apply the towels to the desired area.

g. To maintain constant heat, cover the compress with a hot water bottle, or use infrared lamp, or wrap in a blanket.

h. Apply the compress for 20 minutes, changing every 5 minutes.

i. Check the skin after the removal of the hot compress.

Indications:

If hydrocollator packs are not available, hot compresses can be used as an alternative.[pic]

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