Unlike Heat Miser and Snow Miser from the Christmas classic of old, PTs will not come to blows over which temperature treatment to use on their patients, but there are some definite opinions. "That's probably a heavily debated topic," says Paul Spadino, PT, clinical director of Dynamic Physical Therapy, with 20 locations in Delaware and Pennsylvania.

Some physicians go by rules, such as ice for 48 hours followed by heat. "Case by case, it's a little bit more difficult than that—a lot more individual," Spadino says. He starts heat therapy anywhere between 1 and 2 weeks after an injury, then switches to cold therapy for 2 weeks or so. "Unless cold proves really beneficial, and then I just stick with ice," Spadino says.

Spadino continues to deliver hot and cold therapy despite the shrinking (and, in some instances, nonexistent) reimbursement. Many therapists have stopped delivering hot and/or cold therapy in response to the financial risks. In addition to the low reimbursement levels, the modalities could be the source of bigger expenses: "The lowest-reimbursed modality is hot packs or cold packs, and the number one malpractice suit is hot packs—burns," Spadino says.

Despite the risks, however, hot and cold therapies do provide benefits, which is why Spadino continues to use them in his practice. He estimates that about 80% of Dynamic Physical Therapy's patients undergo heat and/or ice therapy. Each clinic sees between 100 and 500 patients per week; therapists typically visit with 12 to 16 patients in an 8-hour day. "It's a VIP service philosophy that we teach. We don't care if we get paid for it or not, we know it works," Spadino says.

BLOW HOT AND COLD

Both hot and cold therapies reduce pain. The sensory receptors in the skin respond to the temperature stimuli, decreasing pain-signal transmissions to the brain and thereby also decreasing patient discomfort.

Heat also increases circulation in the area, dilating the blood vessels and increasing blood flow. The effect can help to speed healing through improved delivery of oxygen, nutrients, and other healthful resources. It can also increase flexibility. Warm muscles relax better, permitting more movement, a bonus for physical therapy patients undergoing rehabilitation.

Heat is not recommended when swelling is present; cold, however, has the opposite effect. It can help to reduce swelling and is also an excellent analgesic.

Spadino generally starts with heat therapy to relax a patient and increase flexibility, then moves into the physical modalities of the exam (such as manual therapy, electrical stimulation, and/or exercise). "This is really where I think patients benefit the most," says Spadino, who notes that exercise is always a part of patient treatment. The manual techniques are then followed by ice.

"As long as people have symptoms, there is a need for modalities to be used. As the symptoms begin to decrease, then we tend to revamp therapy to go more toward increasing flexibility, strength, and function," Spadino says.

Contraindications are few. Those who are unable to communicate what they are feeling (such as infants) and those with dysfunctional sensory systems are generally not recommended for hot/cold therapy. "Someone with limited sensation, who can't tell temperature differences, may be susceptible to a little frostbite, if using real ice, or a burn," Spadino says.

COLD COMFORT

To maximize treatment delivery, Spadino employs some trusted products.

For heat, he uses a traditional hydrocollator and moisture heat in the clinic; at home, he recommends patients use Thermophore products from Battle Creek Equipment Company, a Medwing Company located in Battle Creek, Mich. "They are as close as you can come to moist heat at home," says Spadino, who believes moist heat is much more effective than the dry heat delivered by a standard heating pad.

Moist heat is often done wrong, in Spadino's opinion. Many clinics have the patient lie supine on the table; below them are a layer of three or four terry cloth towels, the heating pad, another terry cloth towel, and the table. After treatment, Spadino observes, the wettest pad is the one on the bottom, closest to the table and farthest from the patient.

"We replace the bottom terry cloth towel with a vinyl pad that does not absorb water so the moisture is directed up into the patient and not the table, where it goes otherwise," Spadino says.

Spadino is equally innovative with cold therapy. His method of choice uses the Game Ready system by Game Ready, Alameda, Calif. Based on RICE (rest, ice, compression, elevation), Game Ready delivers adjustable cold therapy and intermittent compression simultaneously. "The vasopneumatic compression allows you to aid the reduction of swelling," Spadino says.

The system is comprised of a microprocessor- driven control unit and anatomical sleeves called Dual-Action Wraps: air inflates and deflates chambers within the wraps to create the compression; continuous, rapid circulation of ice water cools the temperature of the sleeves. The PT manages the pressure, temperature, and treatment time through the control unit. "You can drop the knee temperature to about 45 degrees and have the instant cold surrounding the joint," Spadino says.

Wraps have been designed specifically for the ankle, knee/articulated knee, hip/groin, back, shoulder, wrist, and elbow. "The shoulder one is phenomenal because it encompasses the entire shoulder girdle and wraps around the bicep and tricep—much more encompassing than an ice pack," Spadino says.

Spadino was first exposed to the Game Ready system in his previous job. After moving to Dynamic Physical Therapy in early 2007, he initiated the purchase of the system for all of the organization's clinics. "We now have a Game Ready in every clinic," Spadino says.

The acquisitions were not difficult to justify, although they were expensive. Spadino estimates costs for a system fall between $3,200 and $3,500, depending on how many sleeves are desired. But they are typically recouped within 3 months. Dynamic Physical Therapy performed an ROI study on its new Game Readys and found a return on their investment at about 3 months.

Some of the larger clinics have purchased a second unit. "Patients will actually sign a list when they walk into the clinic to get on the Game Ready," Spadino says.

WARMING PATIENTS UP

Spadino understands their excitement—he has used the Game Ready himself. "I'm cynical about a lot of products, so I like to try products out," Spadino says. It became his number one promotion at Dynamic Physical Therapy.

But he doesn't ask people to take his word for it. He insists his therapists try it out, too. Direct experience is an aspect of the VIP service promoted at Dynamic Physical Therapy. "VIP service really is the philosophy that I treat every patient like I would my mother," Spadino says.

It means employing unique methods devised over the years to improve care. Spadino's modifications of heat therapy or the use of the Game Ready are just a few examples.

Therapists trying out their own therapy is another. "So often, therapists get away from what they actually do treatment- wise and just deliver a service because they don't experience it themselves. The best PTs know what something feels like," Spadino says.

VIP service means therapists experience both hot and cold therapy once per year to be cognizant of the sensation. It was through direct experience that Spadino realized the defect in conventional moisture heat therapy. It was also how he learned to improve cold therapy for clients, particularly geriatric patients. "People don't like ice because it's so cold and they get chills," Spadino says. By placing a hot pack on their abdomen, their core stays warm, and they leave happy. "It makes a huge difference," Spadino notes.

It means taking extra care. "VIP service is putting someone on a table in a position of comfort that allows the body to relax and absorb the benefits of the treatment versus holding an awkward position to receive the therapy," Spadino says.

VIP service means using the best techniques without watching the clock or the balance sheet, for example, using hot or cold therapy despite the lack of reimbursement. "We know what quality care is and will continue to deliver these therapies whether we are reimbursed or not, because it is quality," Spadino says.

Because of their utility, Spadino doesn't see hot or cold therapy disappearing from care. He does, however, see a trend toward the less litigious cold. "I don't see ice ever going away," Spadino says.

"I see therapy as a means to restore function in people and improve quality of life," Spadino says. Hot and cold therapy are means by which to achieve that end, a point neither Heat Miser nor Snow Miser are likely to disagree with.

Renee DiIulio is a contributing writer for Physical Therapy Products. For more information, contact .