ELECTROTHERAPY-

II
ASSIGNMENT
CRYOTHERAPY
TOPIC: TECHNIQUES OF
CRYOTHERAPY APPLICATION

MADE BY:
AISHWARYA GUPTA
ROLL NO. - 2
 BPT: 3rd YEAR

INTRODUCTION
The application of cold for various therapeutic purposes is called
cryotherapy. This has clinical applications in both rehabilitation and
other areas of medicine. The temperature of the body tissue is
reduced by application of various forms of ice or frozen gel packs or by
evaporation of volatile fluids from the skin and the heat is transferred
from the body tissue to the cold medium. The magnitude of cooling
depends upon the area of the body tissue exposed, temperature of the
cooling agent and the duration of exposure. The depth of penetration is
also related to the intensity and duration of cold application and the
circulatory response to the body segment exposed. Often, the skin
temperature is reduced to 100C. Thus, for constant source of cooling,
the temperature drop in the tissues will depend upon:

1. Temperature difference between the coolant and the

tissues: The colder the application, the grater the heat loss
from the tissues.
2. Thermal conductivity of the tissues: This differs from one
area to another.
3. Length of time for which the cold is applied: The amount of
energy loss is dependent upon the length of exposure.
4. Size of area that is being cooled: The smaller the area more
will be the cooling.

The primary use of cryotherapy outside of rehabilitation is for the

destruction of malignant and nonmalignant tissue growths, for which
very low temperatures are used and the cooling is generally applied
directly to the tissue being treated. In rehabilitation, mild cooling is
used to control inflammation, pain, and edema; to reduce spasticity; to
control symptoms of multiple sclerosis; and to facilitate movement.
This type of cryotherapy is applied to the skin but can decrease tissue
temperature deep to the area of application including intra-articular
areas. Cryotherapy exerts its therapeutic effects by influencing
hemodynamic, neuromuscular and metabolic processes. Also, the use of
cryotherapy is contraindicated in certain conditions such as: Cold
hypersensitivity, Cold intolerance, Cryoglobulinemia, Paroxysmal cold
cryoglobinuria, Raynaud's disease, Over a regenerating peripheral
nerve and over an area with circulatory compromise or peripheral
vascular disease. Certain adverse effects of cryotherapy are: Tissue
death, Frostbite, Nerve damage and unwanted vasodilatation.
 Techniques of cryotherapy
application
General procedure of application of cryotherapy:
1. Evaluate the patient and set the goals of treatment.
2. Determine if cryotherapy is the most appropriate treatment.
3. Determine that cryotherapy is not contraindicated for this
patient or condition.
4. Select the appropriate cooling agent according to the body part
to be treated and the desired response: Select an agent that
provides the desired intensity of cold treatment, best fits the
location and size of the area to be treated, is easily applied for
the desired duration and in the desired position and is readily
available and is reasonably priced.
5. Explain to the patient the procedure and reason for applying
cryotherapy and the sensations that patient can expect to feel.
During the application of cryotherapy by any means the patient
will usually experience the following sequence of sensation:
 Intense cold
 Burning
 Aching
 Analgesia
 Numbness

6. Apply the appropriate cooling agent.

7. Assess the outcome of treatment.

The various techniques that are used for administrating cold are:
1. Ice massage
2. Ice packs or cold packs
 3. Controlled cold compression unit
4. Evaporating cooling or vapocoolant sprays
5. Immersion in cold whirlpool
6. Contrast bath
7. Excitatory cold

These can be explained as:

1. Ice massage:
In this technique, ice is placed in a polyethylene bag and applied over
the body tissue. Ice cubes, crushed ice or flaked ice, etc. can be used.
Also, ice cups or frozen water popsicles can be used to apply ice
massage. Frozen cups are made by freezing small paper or Styrofoam
cups of water. To use these, the therapist holds on to the bottom of
the cup and gradually peels back the edge to expose the surface of the
ice and puts it in direct contact with the patient's skin. Water
popsicles are made by placing a stick or tongue deep into the water cup
before freezing. When frozen the ice can be completely removed from
the cup and the stick used as a handle for applying the ice. Patients can
easily make ice cups or popsicles at home. These are placed over the
patient’s tissue and moved in a to and fro and circular motion. The
pressure of application should be minimal and the maximum time of
application in about ten minutes.

APPLICATION TECHNIQUE FOR ICE MASSAGE:

EQUIPMENTS REQUIRED:
1. Small paper or Styrofoam cups
2. Freezer
3. Popsicles
4. Towels to absorb water

PROCEDURE:
 1. Remove all jewelry and clothing from the area to be treated and
inspect the area.
2. Place towels around the treatment area to absorb any dripping
water and to wipe away water on the skin during treatment.
3. Rub the ice over the treatment area using small, overlapping
circles. Wipe away any water as it melts on the skin.
4. Continue ice massage application for 5 to 10 minutes or until the
patient experiences analgesia at the site of application.
5. When the treatment is completed, inspect the treatment area
for any signs of adverse effects such as wheals or a rash. It is
normal for the skin to be red or dark pink after the application of
ice massage. Ice massage may be applied in the above manner for
the local control of pain, inflammation, or edema. Ice massage can
also be used as a stimulus for facilitating the production of
desired motor patterns in patients with impaired motor control.
When applied for this purpose the ice is either rubbed with
pressure for 3 to 5 seconds or quickly stroked over the muscle
bellies to be facilitated. This technique is known as quick icing.

ADVANTAGES
 Treatment area can be observed during application of ice
massage.
 Can be used for small and irregular areas.
 Short duration of treatment.
 Inexpensive
 Can be applied to an elevated limb

DISADVANTAGES
 Too time consuming for large areas
 Requires active participation by the clinician or patient
throughout application.
2. Ice
packs or cold packs:
Commercially, used cold packs are used for administrating cold. These
cold packs contain special material which retains the cold like silicate
gel or a mixture of saline or gelatin and are usually covered with vinyl.
The gel is formulated to be semisolid at between 00c and 50C for the
pack to conform to the body contours when it is within this
temperature range. The temperature of a cold pack is maintained by
standing it in a specialized cooling unit or in a freezer at -50C. Cold
packs should be cooled for at least 30 minutes between uses and for 2
hours or longer before initial use .The main advantage of these cold
packs are that they are reusable and can contour or mold themselves
according to body part treated. Ice packs are made of crushed ice
placed in a plastic bag. Ice packs provide more aggressive cooling than
cold packs at the same temperature because ice has a higher specific
heat than most gels and because ice absorbs a large amount of energy
when it melts and changes from a solid to a liquid.

APPLICATION TECHNIQUE FOR COLD PACK/ICE PACK

EQUIPMENTS USED:
 Cold packs of variety of sizes and shapes
 Freezer or specialized cooling unit
 Towels or pillow cases for hygiene or insulation
Ice packs
 Plastic bags
 Ice chips
 Freezer
 Towels or pillow cases

PROCEDURE:
1. Remove all jewelry and clothing from the area to be treated and
inspect the area.
2. Wrap the cold pack or ice pack in a towel. Use a damp towel if a
maximal rate of tissue cooling is desired. It is recommended that
warm water be used to dampen the towel to allow the patient to
 gradually become accustomed to the cold sensation. A thin, dry
towel can be used if slower, less intense cooling is desired. A
damp towel is generally appropriate for a cold pack, whereas a dry
towel should be used for an ice pack since ice provides more
intense cooling.
3. Position the patient comfortably, elevating the area to be treated
if edema is present.
4. Place the wrapped pack on the area to be treated and secure it
well. Packs can be secured with elastic bandages or towels to
ensure good contact with the patient's skin.
5. Leave the pack in place for 10 to 15 minutes to control pain,
inflammation, or edema. The recent systematic review of the
research on cryotherapy found that a 1O-minute application time
is most effective for reducing the pain and swelling associated
with soft tissue injury and minimizing the risk of side effects and
possible further injury. When cold is applied over bandages or a
cast, the application time should be increased to allow the cold to
penetrate through these insulating layers to the skin. In this
circumstance, the cold pack should be replaced with a newly
frozen pack if the original pack melts during the course of
treatment. If cryotherapy is being used to control spasticity the
pack should be left in place for up to 30 minutes. With these
longer applications, check every 10 to 15 minutes for any signs of
adverse effects.
6. Provide the patient with a bell or other means to call for
assistance.
7. When the treatment is completed, remove the pack and inspect
the treatment area for any signs of adverse effects such as
wheals or a rash. It is normal for the skin to be red or dark pink
after icing.
8. Cold or ice pack application can be repeated every 1 to 2 hours to
control pain and inflammation.
ADVANTAGES:
 Easy to use
 Inexpensive materials and equipment
 Short use of clinician's time
 Low level of skill required for application
 Covers moderate to large areas
 Can be applied to an elevated limb

DISADVANTAGES:
 Pack must be removed to visualize the treatment area during
treatment
 Patient may not tolerate weight of the pack
 Pack may not be able to maintain good contact on small or
contoured areas
 Long duration of treatment compared to massage with an ice cup

ICE PACKS VS COLD PACKS

 Ice pack provides more intense cooling
 Ice pack is less expensive
 Cold pack is quicker to apply
 3. CONTROLLED COLD COMPRESSION
UNIT:
Controlled cold compression units alternately pump cold water and air
into a sleeve that is wrapped around the patient’s limb. The
temperature of the water can be set at between 10 0C and 25 0C to
provide cooling. Compression is applied by intermittent inflation of the
sleeve with air. Controlled cold compression units are most commonly
used directly after surgery for the control of post operative
inflammation and edema; however they may also be used to control
inflammation and related edema in other circumstances. When applied
postoperatively the sleeve is put on the patient's affected limb
immediately after completion of the surgery while the patient is in the
recovery room and the unit is sent home with the patient so that it can
be used for a few days or weeks after surgery. The application of cold
with compression in this manner has been shown to be more effective
than ice or compression alone in controlling swelling, pain, and blood loss
after surgery and in assisting the patient in regaining ROM.

APPLICATION TECHNIQUE
EQUIPMENT REQUIRED:
 Controlled cold compression unit
 Sleeves appropriate for area to be treated
 Stockinette for hygiene

PROCEDURE:
1. Remove all jewelry and clothing from the area to be treated and
inspect the area.
2. Cover the limb with a stockinette before applying the sleeve.
 3. Wrap the sleeve around the area to be treated.
4. Elevate the area to be treated.
5. Set the temperature at 100 to 15 0C. Cooling can be applied
continuously or intermittently. For intermittent treatment apply
cooling for 15 minutes every 2 hours.
6. Cycling intermittent compression may be applied at all times when
the area is elevated.
7. When the treatment is completed, remove the sleeve and inspect
the treatment area.

ADVANTAGES:
 Allows simultaneous application of cold and compression
 Temperature and compression force are easily and accurately
controlled
 Can be applied to large joints

DISADVANTAGES:
 Treatment site cannot be visualized during treatment
 Expensive
 Usable only for extremities
 Cannot be used for trunk or digits
 4. EVAPORATING COOLING OR
VAPOCOOLANT SPRAYS:
The use of vapocoolant sprays is increasing nowadays. These are being
used very commonly in sporting activities or athletics injuries. The
commonly used sprays are fluoromethane or ethyl chloride. The jet of
spray is usually applied from a distance of about 1 feet or 12 inches.
Gentle stretch is applied to the tissues after application of vapocoolant
sprays. Rapid cutaneous cooling is generally used as a component of the
treatment of trigger points. For this application, the vapocoolant
spray or brief icing is applied in parallel strokes along the skin
overlying the muscles with trigger points immediately before
stretching these muscles. This type of treatment is
frequently applied directly after trigger point injection. The
purpose of the rapid cooling is to provide a counterirritant
stimulus to the cutaneous thermal afferents overlying the
muscles to cause a reflex reduction in motor neuron activity
and thus a reduction in the resistance to stretch. The
"distraction" of rapid cutaneous cooling is intended to
promote greater elongation of the muscle with passive
stretching. The combination of spraying with vapocoolant
spray followed by stretching is known as "spray and stretch."

APPLICATION OF VAPOCOOLANT SPRAYS:

PROCEDURE:
1. Identify trigger points and their related tight muscles.
2. Position the patient comfortably, with all limbs and the back well
supported and the area to be treated exposed and accessible.
Inspect the area to be treated. If using ethyl chloride spray,
protect the surrounding areas of skin with petrolatum to avoid
 excessive cooling. Because Fluori-Methane produces less intense
cooling than ethyl chloride, the surrounding areas of skin do not
need protection when Fluori-Methane is being used.
3. Apply two to five parallel sweeps of the spray or brief ice
massage at a speed of approximately 10 cm per second along the
direction of the muscle fibers. When using a spray, hold the
bottle about 45 cm from the skin and angled so that the spray
hits the skin at an angle of about 30 degrees. If applying spray
near or around the patient's head, try to minimize the patient's
inhalation of the spray, early with ethyl chloride, since this
substance produce general anesthetic effects.
4. During the cooling, maintain gentle, smooth, tension on the muscle
to take up any slack that develop.
5. Immediately after the cooling, have the take a deep breath and
then perform a gentle passive stretch while exhaling.
Contraction-relaxation techniques may also be used to enhance
the ROM increases obtained with this procedure.
6. Following this procedure, the skin should rewarmed with moist
heat, and then the muscle should be moved through their full
active ROM.

ADVANTAGES:
 Brief duration of cooling
 Very localized area of application

DISADVANTAGES:
 Fluori-Methane spray damages the ozone layer
 Limited to use for brief, localized, superficial application of cold
before stretching
 Possible narcotic or general anesthetic effect if ethyl chloride is
inhaled.
 5. IMMERSION IN COLD WATER:
The part of body is immersed in cold water or a whirlpool in which
temperature of water is lowered up to 0-10C. Flaked ice or crushed ice
is used in a solution with water to form slush. Extremities of the body
can be effectively treated with immersion in the cold. The total
duration is around 10 minutes in which the patient can immerse in
either for a single 10 minutes session or for a series of shorter
immersions until accumulative total of 10 minutes have been reached.

APPLICATION TECHNIQUE:
EQUIPMENTS REQUIRED:
 Hot and cold water mixing valves
 Thermometer for checking the temperature of the water in the
tank
 A turbine to agitate and aerate the water
  Seat or stretcher for the patient to sit either in or out of the
water depending on the area being treated and the configuration
of the whirlpool
 Gravity drain
 Heated, well-ventilated space
 Towels and blankets

PROCEDURE:
1. Fill the tank with water. Select the appropriate temperature
range according to the condition and treatment objectives. A cold
whirlpool, at 00 to 260 C should be used for the treatment of
acute inflammatory conditions of the distal extremities. Low
temperatures can be achieved by adding ice to the whirlpool
water; however, very low temperatures should not be used on
large areas due to the increased risk of tissue damage.
2. Allow the patient to undress the area to be treated, and provide
a gown or halter and pants as necessary. Do not allow any clothing
to enter the water because it may be sucked into the turbine
3. Remove wound dressings if any are present and if they are easy
to remove without causing pain or damaging the tissue.
4. Position the patient comfortably with the affected area
immersed in the water. Try to avoid pressure of the limb on the
edge of the whirlpool in order to avoid impairing circulation or
nerve function or causing discomfort.
5. Adjust the direction and aeration of the turbine. The entire
turbine can be moved from side to side and up and down to adjust
its direction.
6. Turn on the turbine
7. Stay with the patient throughout the hydrotherapy treatment
and monitor the patient's vital signs before, during, and after
treatment as necessary.
 8. When the treatment is completed, remove the limb from the
water dry the intact skin thoroughly, and inspect the treated
area.

ADVANTAGES:
 Patient can be positioned securely and comfortably
 Weaker muscles can move more freely than on dry land.
 Allows movement while treatment is given

DISADVANTAGES:
 Size of tank limits the amount of exercise and the size of the
area that can be treated.
 Large quantity of water used.
 Risk of infection.
 Costs associated with cleaning.
 Costs associated with cooling water.
 Time expended assisting the patient to dress and undress
 6. CONTRAST BATH:

Contrast baths are applied by alternately immersing area, generally a

distal extremity, first in warm hot water and then in cool or cold
water. Though there are no published research data on effects of
contrast baths, since this form of hydrotherapy is thought to train the
vascular system by inducing alternating vasodilatation and
vasoconstriction, it is frequently used clinically when the goal of
treatment is to decrease edema. The varying sensory stimulus is also
thought to promote pain relief and desensitization. Thus treatment
with a contrast bath may be considered when patients present with
chronic edema; sub acute trauma; inflammatory conditions such as
sprains, strains, or tendonitis; or hyperalgesia or hypersensitivity due
to reflex sympathetic dystrophy or other conditions.

APPLICATION TECHNIQUE
EQUIPMENT REQUIRED:
 Two water containers
 Thermometer
 Towels

PROCEDURE:
1. Fill two adjacent containers with water. The container may be
whirlpools, buckets, or tubs. Fill one container with warm or
hot water at 380 to 44 0C, and the other with cold water at
100-180C. When using contrast baths for the control of pain or
edema, it is recommended that the temperature difference
between the warm and cold water be large; when using
contrast baths for desensitization, it is recommended that the
 temperature difference between the two baths initially be
small and then gradually increased for later treatments as the
patient's sensitivity decreases.
2. First, immerse the area to be treated in the warm water for 3
to 4 minutes; then immerse the area in the cold water for 1
minute.
3. Repeat this sequence five or six times to provide a total
treatment time of 25 to 30 minutes and end with immersion in
the warm water. When the treatment is completed, dry the
area quickly and thoroughly

ADVANTAGES:
 May promote a more vigorous circulatory effect than heat or cold
alone
 Provides good contact with contoured distal extremities
compared with other thermal agents.
 May help to provide pain control without aggravating edema.
 Allows movement in water for increased circulatory effects

DISADVANTAGES:
 Limb is in a dependent position, which may aggravate edema.
 Some patients do not tolerate cold immersion.
 Lack of research evidence to support the effect of contrast
baths on circulation
7. EXCITATORY COLD:
The marked sensory stimulus of ice on the skin can be used to facilitate
contraction of inhibited muscle. Ascertain the spinal root level supply
(myotome) of the inhibited muscle and find the area of the skin which has
same root supply (dermatome). The ice is stroked quickly three times over
the dermatome and skin is then dried. This sensory stimulus passes via the
peripheral nerve and enters the cord through posterior horn. It raises the
level of excitation around the anterior horn cell (as acetyl choline has
connection with these sensory fibres). The increased excitation may
supplement the patient’s willing effort to make the muscle contract. This
technique of “quick ice” is often a useful stimulus aiding voluntary
contraction of muscle. This effect can be used where muscles are inhibited
post-operatively, or in later stages of regeneration of a mixed peripheral
nerve.