Post on 12-Nov-2014
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CryotherapyCryotherapy
ByDr Ruchika gupta
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• Applying cold therapy will cause:– the skin temperature can be changed
abruptly. – the deeper tissues are cooled more
slowly. • it takes some 30 min to lower the muscle
temperature at a depth of 4 cm by 3.5°C • Muscle tissue at 2.5 cm can take up to 20 min or
longer to drop 5°C• When apply cold over thin
subcutaneous fat layer for example knee joint – the intra-articular temperature of the knee
joint fell by an average of 9.4°C due to the application of ice bag for 30 min to the front of the knee.
Physiologically what happens Physiologically what happens when we use cold modalities to when we use cold modalities to manage acute trauma?manage acute trauma?Hemodynamic EffectsCellular Metabolism EffectsNeurological EffectsNeuromuscular Effects
◦Strength◦Spasm◦Neuromuscular control
Hemodynamic EffectsHemodynamic EffectsImmediate Response
◦ Vasoconstriction @ arterioles and venulesCauses of Vasoconstriction
◦ Direct action on smooth muscles◦ Decrease the production/ release of vasodilators
mediators such as Histamine & Prostaglandins.◦ Reflexive cutaneous vasoconstriction
Hunting Reflex◦ Describes switching VD and VC◦ Have VD but overall maintain VC state
Cellular Metabolism AffectsCellular Metabolism Affects
Secondary Hypoxic (Ischemic) Injury◦ Decrease oxygen◦ Inadequate fuel
substrates◦ Inadequate waste
removal
Attempt to reduce Secondary Injury
Cellular ResponseCellular ResponseCold application decreases need for O2 at
the injury siteDecreased need for O2 results in a decrease
in secondary cell deathDecrease in secondary cell death causes a
smaller amount of inflammatory substances to be released.
Decreased cellular metabolism– 20 minute of ice application decrease metabolism approx. 20% (Ho et. al. 1995)
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Reduced Secondary Tissue Reduced Secondary Tissue InjuryInjury
Cryotherapy
Heat transfer
Decrease metabolic activity
Decrease ATP demand
Decrease O2 demand
Increase tissue survival
Merrick, MSSE, 1999
Neurological Effects Neurological Effects (Peripheral Nerves)(Peripheral Nerves)Alters conduction velocities
◦ Decrease sensory◦ Decrease motor conduction velocities◦ Impeded or blocked synaptic transmission◦ Sensory fibers affected first?
A-delta and C fibers Conduction velocities decreased
Larger A fiber (alpha and beta affected last) Gamma motor neurons also affected Lager A fibers and gamma motor neuron
important in reducing spasm
Why do we use cryotherapy?Why do we use cryotherapy?
Local Effects of Cold Local Effects of Cold ModalitiesModalitiesVasoconstrictionDecreased cellular metabolismDecreased cellular waste
productionReduction in inflammationDecreased painDecreased muscle spasm
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Pain Control Reduce Secondary Tissue Injury
Pain Control Pain Control
Gate Control◦ What afferent
fiber?Conduction
Velocities◦ Pain sensory fibers
Lee et al, Physiother, 1978
◦ Gamma motor neurons
Pain Control– cold affects pain perception by:• interrupting pain transmission• decreasing nerve conduction
velocity• reducing muscle spasm• limiting edema
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Control InflammationControl InflammationCold suppresses inflammatory response:• reducing the release of inflammatory
mediators• decreasing prostaglandin synthesis• decreasing capillary permeability• degree of hemorrhaging and edema are
reduced by limiting inflammatory mediators• Pain is decreased by lessening the
mechanical pressure on nerves.
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Reducing SpasmReducing SpasmMuscle spindles and GTO’s not work properly.Group Ia and II fibers reduce frequency of
discharge.Alpha motorneuron firing decreases.End resultDecreased stretch reflex sensitivityDecrease pain by reducing the threshold of
afferent nerve endings.Decreases the sensitivity of muscle spindles.
9 F drop will reduce muscle spindle sensitivity
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PHYSIOLOGICAL PHYSIOLOGICAL CHANGESCHANGES
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PHYSIOLOGICAL CHANGES DUE TO PHYSIOLOGICAL CHANGES DUE TO COOLING THE SKINCOOLING THE SKIN
• Applying cold therapy to the skin will cause ‘hunting reaction’ – a dramatic vasoconstriction leads to
decrease in blood flow through the skin– And increased the blood viscosity which
contribute to the slowed blood flow.• After some minutes the
vasoconstriction may give way to a marked vasodilatation before being replaced by another episode of vasoconstriction.
• It occurs rapidly in the face, especially the nose and ears, but also in the hands, feet, patella region, olecranon, buttocks and some parts of the chest wall.
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Hunting ResposeHunting Respose• This is a protection response to the
tissues from damage due to prolonged cooling and relative ischaemia.
• It depend on the region especially the regions that normally exposed to pressure such as buttocks, anterior surface of knees and particularly the feet.
• This response is variable from person to person.
• It tends to occur about 5-15 min after cold.
• The arteriovenous anastomoses in the skin play a predominant role.
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The cause of this vasodilatation is still not completely elucidated, but it could be due to:
•axon reflex mechanism • involving a histamine-like substance
(substance H) to cause local vasodilatation.
• As the increased blood flow washes out this substance the vessels constrict again thus continuing the cycle.
.
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On metabolic rateThe principal effect of cooling
living tissue will be to reduce its metabolic rate.
• It will reduced oxygen uptake–the erythema due to cold-induced
vasodilation is distinguished from that due to heating due to its ‘pinkness’ because it contains less reduced haemoglobin.
• Thus cooling does not benefit the healing process.
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peripheral nervous peripheral nervous systemsystemCold application to the skin
provides a strong sensory stimulus to cold receptors. ◦ May suppress pain
reduces the conduction velocity of peripheral nerves (motor and sensory) and delays synaptic transmission.◦ Decrease hypertonicity
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Recent injuriesRecent injuriesReduce bleeding
◦Superficial bleeding (cooling must not be intense or so prolonged as to delay blood coagulation).
◦deep bleeding (haematoma) needs long time cold application.
Cutaneous heat burns ◦requires rapid cooling of the area,
lowers the tissue temperature and thus limits tissue damage.
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Soft tissues injurySoft tissues injury
Cooling will diminish the rate of swelling and production of irritants and so alleviate the pain.
It part of PRICE technique (protection, rest, ice, compression and elevation).
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Relief PainRelief Pain
It could be due to:Reducing edema
◦Less pressure and reduce irritant substances release.
Pain conduction ◦Reduces the velocity and number of
impulses of the pain receptors and neurons.
Releasing of endorphins and encephalins
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Relief Muscle spasmRelief Muscle spasmMuscle spasm is linked to pain There is therefore a reasonable
expectation that the application of cold would reduce muscle spasm and so allow an increased range of movement.
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SpasticitySpasticityBrief contact is used
therapeutically to facilitate muscle contraction — ◦briefly stroking with ice cube over the
appropriate dermatome, for example. Ice stroking over the biceps for
1—2 min has been shown to enhance the motor unit activity of subjects
Cutaneous contact ◦ diminishing gamma motor neuron
activity or at least in some way diminishing the muscle spindle discharge, and reducing spasticity.
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Muscle strengtheningMuscle strengtheningSome studies reported that ice
application will increase the isometric strength.
Others reported that ice application will decrease the muscle strength.
These contradictory findings may thus be reflecting a difference in the degree of cooling in different investigations,◦ the shorter applications stimulating the
nervous system, while prolonged intensive cooling affects muscle metabolism leading to weakness.
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Chronic inflammatory Chronic inflammatory conditionsconditionsDegenerative and chronic joint
diseases have been treated successfully with cold therapy, including osteoarthrosis and chronic rheumatoid arthritis. ◦ pain-relieving effect ◦control such minor acute or subacute
inflammatory changes as occur from time to time with degenerative joint conditions.
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Chronic oedema and joint Chronic oedema and joint effusionseffusionsReduce chronic oedema like in
stroke patients.It could be do to
◦ Hunting response◦ Vasoconstriction (acute)
Cryotherapy - IndicationsCryotherapy - IndicationsAcute injury or inflammationAcute or chronic painSmall, superficial first degree burnsPost surgical pain, and edemaUse in conjunction with rehab
exercisesAcute or chronic muscle spasmNeuralgia
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IndicationsIndications
Cold is indicated under three conditions:In the acute stages of the inflammatory
reactionBefore range-of-motion exercisesAfter physical activity
• highly motivated patients (athletes) often return quickly to activity (before full healing)• cold is often used for an extended time period when compared to the general population
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Cryotherapy - Cryotherapy - ContraindicationsContraindicationsCardiac or respiratory
involvementUncovered open woundsCirculatory insufficiencyCold allergyAnaesthetic skinAdvanced diabetesRaynaud’s phenomenonHypersensitivity -hives
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ContraindicationsContraindications Raynaud’s Phenomenon- A vascular reaction (usually
benign) to cold application that results in white, red, or blue discoloration of the extremities (fingers and toes).
thromboangiitis obliterans (Buerger’s disease) Presence of abnormal protein (Cryoglobinaemia)
(systemic lupus erythematosus and rheumatoid arthritis) Cold urticaria. Cold causes the release of histamine from
mast cells leading to a local weal and erythema and sometimes general (systemic) symptoms such as lowered blood pressure and raised pulse rate.
Cardiac disease◦ Coronary thrombosis and anginal pain have
sometimes been provoked (may induce vasoconstriction).
Arterial blood pressure (high blood pressure)◦ When immerse large area could increase the
blood pressure.35
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METHODS OF APPLYING METHODS OF APPLYING COLD THERAPYCOLD THERAPYExplain to the patientPrepare the patient.
◦ Preparation of part.◦ A suitable position depending on whether it is
to be immersed or have a pack applied. ◦ The need for elevation and relaxation.
Instructions for the patient. ◦ increased pain or discomfort.
Application. ◦ check the application every few minutes and
inspect the skin at the same time. Termination.
◦ the skin is dried and inspected.
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Local immersionLocal immersionIt involves placing the part in a
container of iced water — a mixture of water from the cold tap and flaked ice.
At temperatures around 16—18°C continuous immersion can usually be tolerated for 15—20 min.
At lower temperatures, such as around 10°C, continuous immersion is uncomfortable◦intermittent application is usually given (1
min). Used for hand, forearm, foot and leg.
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Cold packsCold packs
Ice packsFlaked ice is folded into damp terry-
towelling or put into bags made of the same material and applied directly to the skin.
Danger of ice burnUsed for 20 minCommercial cold packsThese are basically plastic, often vinyl, bags
filled with a mixture of water and some substance such as Silica gels are the most common.
The pack will be stored at a temperature below 0°C, often —5°C or even —12°C.
Applied over a wet towel for 20 min.
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Ice massageIce massagesolid piece of ice, either as an ice
cube wrapped in paper or cloth or an ice ‘lollipop’ on a wooden stick
There are two distinct purposes for ice massage:◦For the relief of pain, the ice block is
moved over the part using a slow circular motion for some 5—10 min.
◦For neurological facilitation the ice should be applied only briefly, either dabbing for about 4 s at a time or short strokes.
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Cold-compression unitsCold-compression unitsCold therapy combined with
intermittent compression devices to a limb segment are available. Cold water is circulated in a sleeve which is put over the limb and part of it is inflated at intervals.
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Evaporating spraysEvaporating spraysSpraying a rapidly evaporating liquid
on the skin has the effect of using heat energy and hence cooling the surface.
Ethyl chloride or fluorimethane (non-flammable)
The liquid is sprayed on to the area to be cooled in a series of short strokes of about 5 s each with a few seconds’ interval between each.
The nozzle of the spray is held about 45 cm from the skin surface and close to a right angle.