CRYOTHERAPY / COLD THERAPY Sekar.L

Historical perspective –Ancient Greeks and Romans. –Late 1880’s, cold compresses after surgery –Early 1960’s, cold therapy widely recognized by healthcare as a result of studies by Grant (1964) and Hayden (1964). Military studies.

Why Ice?  Mild cooling often used in an effort to control:  Inflammation  Pain control  Reduce spasticity

INTRODUCTION  Cryotherapy refers to the use of local or general body cooling for therapeutic purposes.  Cooling the body surface is simply the transfer of heat energy away from the tissues.  The primary methods of cooling are;  CONDUCTION  CONVECTION

PHYSIOLOGICAL CHANGES OF COOLING 1. ON CUTANEOUS BLOOD VESSELS:- There is immediate vasoconstriction of cutaneous blood vessels, shown by the BLANCHING. After some minutes the vasoconstriction may give rise to a marked vasodilatation (AXON REFLEX MECHANISM) & being replaced by another episode of vasoconstriction.

This alteration of vasoconstriction & vasodilatation is called as LEWIS HUNTING REACTION.(This occurs because to protect the tissues from damage to prolonged cooling & relative ischemia)  2. ON MUSCLE BLOOD FLOW:- The cooling provokes vasoconstriction in all vascular smooth muscles

Reduced Secondary Tissue Injury Cryotherapy Heat transfer Decrease metabolic activity Decrease ATP demand Decrease O2 demand Increase tissue survival

 3. ON METABOLIC RATE:- Decrease in metabolic rate (Decrease in oxygen uptake, so cooling does not benefit the healing process)  4. ON THE PERIPHERAL NERVOUS SYSTEM:- It provides strong sensory stimulus by stimulating the cold receptors. (It decreases the nerve conduction velocity of the peripheral nerves & synaptic transmission can also be delayed)

 5. ON THE MOTOR SYSTEM:- The muscle strength is decreased by cooling. The motor skills are decreased, Decrease in velocity of movement & finger tapping speed.

SENSORY PERCEPTION  1. COOLING / CHILLING  2. BURNING  3. EXTREME PAIN / INTOLERABLE PAIN(ACHING)  4. NUMBNESS

THERAPEUTIC EFFECTS OF COLD  1. RECENT INJURIES / ACUTE INJURIES (OEDEMA REDUCTION)  “RICES-S RULE”  R – Rest  I – Application of ice leads to – Immediate vasoconstriction, Increased viscosity of blood, Decreased blood flow, Metabolic rate & Chemical irritants – Decrease in rate of inflammatory response resulting in Decrease in oedema formation.  I – Immobilization

 C – Compression  E – Application of appropriate electrotherapy modalities & the elevation of the part above the heart level. (Gravity to assist in reduction of swelling)  S – Shock treatment  S – Support the part with splint

 2. PAIN – DIRECTLY BY ACTING ON CONDUCTION OF PAIN RECEPTORS & NEURONS, REDUCING THE VELOCITY & NUMBER OF IMPULSES.(A-Beta & C – fiber stimulation)  Pain gate mechanism & also may release endorphins & encephalin (Counter irritant effect).  Finally – Analgesic effect.  3. REDUCTION OF MUSCLE SPASM –  Pain – spasm – pain cycle (Inter related)

 4. REDUCTION OF MUSCLE SPASTICITY-  Cutaneous effect by Decrease in gamma motor neuron activity. (Decreasing the muscle spindle discharge)  Changes in viscoelastic property – Intrafusal & Extrafusal muscle fibers.  5. CHRONIC INFLAMMATORY CONDITIONS ( O.A, CHRONIC R.A.) –  Pain relieving effect & control of sub acute inflammatory changes.  6. CHRONIC OEDEMA & JOINT EFFUSION-  Decreases intravascular fluid pressure via decreasing blood flow, increased viscosity

7. Facilitation of Muscle static Contraction  Brief application (few seconds) facilitates alpha motor neuron activity.  Produces muscle contraction in flaccid muscle. ( CVA, SCI)  Prolonged cold (few minutes) decreases force of contraction – leading to weakness. 8. Prophylactically after exercise to decrease DOMS  Delayed Onset Muscle Soreness  Due to muscle connective tissue damage secondary to exercise

INDICATIONS  Musculoskeletal trauma  Edema/hemorrhage control & analgesia  Pain  Muscle spasm  Spasticity  Adjunct in muscle re-education  Reduction in metabolic activity

Contraindications to Cryotherapy  Cold sensitivity - Reynaud’s Phenomena  Cold Urticaria  Cold induced Hemoglobinuria and Cryoglobinaemia

Compromised circulation or sensation Cardiac diseases Emotional & psychological features

Reynaud’s Phenomena:- It is condition often associated with connective tissue disorder – digital arteries. It exhibits cycles of pallor, cyanosis, rubor & normal color in the hands & feet in response to cold. Numbness, tingling or burning may also occur.

Cold Urticaria:- It is a very cold sensitive condition. It is characterized by raised reddened areas. The systemic response may include – facial flushing, a drop in B.P., a increase in pulse rate & syncope.

Cryoglobinaemia:- An abnormal protein is present in the blood, it can form a precipitate at low temperatures blocking blood vessels & thus causing local ischemia. It is not common, but can be found in association with some of connective tissue disorders. Hemoglobinuria:- It is characterized by the presence of blood in the urine.

Compromised circulation or sensation:- Cold application may lead to burns Cardiac diseases:- Coronary thrombosis & anginal pain have sometimes been provoked by cold. (Since it put heart a greater demand due to increased B.P.)

Emotional & psychological features:- This is more likely to seen in elderly patient’s, because the control mechanism is becoming less efficient in old age.

Precautions:-  Over superficial main branch of a nerve  Over an open wound - delays healing  Hypertension - can cause transient increases in systolic or diastolic BP  Patients with poor sensation  Very young or very old  impaired temperature regulation,  ability to communicate

Adverse Effects  Tissue Death  Frost Bite  Nerve damage  Freezing of tissues

METHODS OF APPLICATION OF CRYOTHERAPY 1.LOCAL IMMERSION METHOD (ICE BATH / COLD BATH) 2.ICE PACKS 3.COMMERCIAL COLD PACKS 4.ICE TOWELS 5.ICE MASSAGE 6.COLD COMPRESSION UNITS 7.EVAPORATING SPRAYS

LOCAL IMMERSION METHOD (ICE BATH / COLD BATH)  This is the simplest method of all.  It involves placing the treatment part in a container (Plastic or rubber best) of iced water (Not ice water submersion)– a mixture of water from the cold tap & flaked ice.  This method is primarily used for distal extremities.(Hand, forearm, foot & leg)  Immersion of the body part allows complete conformity of the cooling to the skin.

 Initial cooling usually quite painful.  Assuring patient that subsequent bouts and sessions will be much less painful.  Using a toe cap to minimize pain.  At temperatures around ˚C continuous immersion can usually be tolerated for 15 – 20 min.  At around 10˚C, continuous immersion is uncomfortable, so that intermittent application is usually given.

 Once numb, body part can be removed from immersion and ROM exercise can be performed  As pain returns re- immersion should take place  Cycle can be repeated 3 times

ICE PACKS  These are a simple & effective method for cooling tissues.  Flacked ice is folded into damp terry toweling or put into bags (POLYTHENE BAG) made of the same material & applied directly to the skin.  They may be held in place by a plastic sheet wrapped around the part & the pack.

 A further towel is occasionally wrapped outside the plastic to decrease the heat gain to the ice pack from the outside air.  Cooling of the skin is quite rapid at the first.  These packs are quite tolerable for some 20 min.

ICE PACKS  Equipment:  Plastic bag filled with ice cubes or crushed ice  Technique:  Fill bag with ice & seal well to prevent leakage  Duration: 5-15 min  Advantages:  Can mold to part being Rx’d  Disadvantages: Bag can leak

COMMERCIAL COLD PACKS  These are basically plastic, often vinyl bags filled with a mixture of water & some semi-gelled substance.  These packs will remain flexible & can be molded to the part.  Silica gels are the most common.  It comes with various sizes & shapes like hydrocollator packs.

 The cold packs are placed in freezer units & remain cold up to 15 – 20 min after removal from cooling unit.  These packs are initially at lower temperature than ordinary ice packs & potentially cool the skin very rapidly.  They may be applied either directly to the skin or can be used with a wet towel depending on the desired intensity of the cold application.

 The cold packs confirm to the irregular surface areas & maintains a constant temperature – may be problematic.  The cold packs are reusable & self contained.  The main advantage if these packs seems to be convenience.

COMMERCIAL COLD PACKS  3 types:  Clinical type: durable plastic cover around silica gel & stored in refrigerator tank  Home type: similar but smaller than clinical type; purchased in pharmacies & stored in freezer  Disposable type: activated by breaking inner seal that mixes chemicals within  Equipment: stored in refrigeration tank like one used for hot packs with temp about 10 – 15 F

 Technique:  Use wet, well wrung out towel next to skin (wet towel hastens cooling of part being Rx’d, because moisture increases rate of thermal conductivity)  Duration: min  Advantages:  reusable  Can be used immediately after injuries such a as sprains or fractures

ICE TOWELS  A terry towel is put into a mixture of flaked ice & water & then wrung out, much of the clipped ice will be found to adhere to the cloth.  This can be placed over a large area to give immediate surface cooling.  The ice towel will need to be replaced by another one after 2 – 3 min.  It is particularly useful method for the treatment of muscles & allows movement or exercise to be performed while cold therapy is being applied.

ICE TOWELS  Technique:  Towels thoroughly soaked in water & ice mixture  Towel wrung out & applied to part; Procedure repeated every few min  Duration: min  Advantages:  Equipment required is available almost anywhere  Disadvantages:  Therapist must keep changing towels

ICE MASSAGE / LOLLIPOP METHOD  This is the application of ice directly onto the skin surface.  It is an intense cold application & usually applied to small areas (Muscle belly or Trigger point)  Either paper or Styrofoam cups or an ice lollipop on a wooden stick is placed in the freezer.  The use of paper or Styrofoam cups or wooden stick provide insulation to the therapist handling the ice.

 Being larger, the lollipop lasts longer & is easier to handle than the usual size of ice cube.  Ice massage produce a counter irritant effect.  Two distinct purpose of ice massage:- 1.Pain relief – The ice block is moved over the part using a slow circular motion for 5 – 10min. 2.Neurological facilitation – The ice should be applied only brief, short strokes. The application should be over the dermatome supplied by the same nerve roots as those of the muscle that is to be stimulated. (The fusimotor fibers of the muscle spindle)

Adding a plate weight will increase numbness.

Ice massage  Stroking of ice on body part to numb skin  Equipment:  Ice that is frozen in insulated cup  “Lollipop”: Ice in cup with small tongue depressor frozen in middle  Ice cube wrapped in paper towels or washcloth

 Technique:  Sensation = cold, burning, aching, numbness  Part being Rx’d may become pale & eventually red  Ice should be applied in circular, smooth, rhythmical strokes  Duration: 3-10 min  Advantages  Numbs skin easily in short time  Ice colder than chemical cold packs  Ice readily available  Disadvantages: ice may cause frostbite

COLD COMPRESSION UNITS  Cold therapy combined with intermittent compression devices to a limb segment.  Cold water is circulated in a sleeve which is put over the limb & treatment part of it is inflated at intervals.

COLD COMPRESSION UNITS

Vapocoolant / Evaporating Sprays  Spraying a rapidly evaporating liquid on the skin has the effect of using heat energy & hence cooling the surface.  Fluori-methane, non-flammable substance that is released in fine spray from pressurized canister.  The nozzle of the spray is held about 45cm from the skin surface & close to a right angle.  Apply spray about 5sec with a few seconds interval between them for 2 – 3 times.

Vapocoolant / Evaporating Sprays  Method of cooling the skin by the evaporation of a substance sprayed on the skin  Equipment: Fluori-Methane  Liquid begins to evaporate & continues to evaporate when contacts skin, thus cooling skin briefly  Technique  Expose area to be Rx’s  Eyes should be protected  Hold bottle in an inverted position at a 30 angle, 18 inches away at a rate of 4 inches per sec.

 Duration Spraying should not exceed 6 sec  Advantages:  Immediate reduction of pain  Can use on joint sprains to relieve pain & swelling  Can use on thermal burns to decrease pain, erythema, & blistering

Cryokinetics  Technique that combines Cryotherapy with exercise  Goal is to numb region to point of analgesia and work towards achieving normal ROM  Equipment  Treat area with ice pack, massage or immersion  Application  When analgesia is experienced, exercises should be performed.  As pain returns, process may be repeated  Sequence can be repeated 5 times  Exercises should be pain free  Changes in intensity should be limited by both healing and patient’s perception of pain

Cold decreases pain, which Facilitates active exercise Exercise Reduces swelling (dramatically) through muscular milking action Promotes healing and return to function Reduces inhibition

Cryostretch Combination of the muscle spasm reduction techniques  Cold application  Static stretching  Hold–relax technique of PNF

Ice decreases pain and muscle spasm. Static stretching overcomes stretch reflex, thus decreasing muscle spasm. Relaxation after maximal muscular contraction is greater than before contraction.

Clinical Parameters Taught in PT School  Ice Bath 13°C to 18°C 10 to 30 minutes  Ice Towel 0°C 5 to 15 minutes  Ice Pack 0°C 5 to 15 minutes  Commercial Cold Pack -12.2°C to –9.4°C 10 to 15 minutes  Ice Massage 0°C 3 to 10 minutes