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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.