Cryotherapy

lecture 8
Dr. Gaber Sayed

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 OUTLINES
 Definition
 Physical principles
 Physiological effects
 Indications
 Contraindications
 Modalities

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 Cold therapy (Cryotherapy)

 Used as first-aid after trauma

 Used as adjunctive tool in
rehabilitation of musculoskeletal
and neuromuscular dysfunctions

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Physical Principles
 Cooling = heat abstraction: heat
removed or lost from an object
 Therapeutic cooling through
1. Conduction
2. Evaporation

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Conduction
 It is the transfer of heat by the direct
interaction of the molecules in the hot
area with those in the cooler area
 Internal energy gained by the slower
moving, cooler particles from the more
rapidly moving hotter particles

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Conduction
 Temperature change depends on:
1. Temperature difference between the cold object and
the tissue
2. Time of exposure
3. Thermal conductivity of the area being cooled
4. Type of cooling agent
D = area . k . (T1 – T2)
Thickness of tissue
D = rate of heat loss (cal/sec)
Area = amount of body surface area cooled or heated
(cm2)
K = thermal conductivity of tissues (cal/sec/cm2XoC/cm2)
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T1 & T2 = temperatures ofRHS,327
warm and cool surfaces (oC) 6
 Conduction
1. Temperature Gradient
The greater the Temperature Gradient between Skin &
Cooling Source

The greater tissue Temperature Change
Example:
15 min immersion of forearm in 1oC  subcutaneous
tissue temp. drop 24oC
15 min immersion of forearm in 17oC  subcutaneous
tissue temp. drop 6oC

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Conduction
2. Time of Exposure
The deeper the tissue

The longer the time required to lower temp.
3. Thermal Conductivity
= measure of the efficiency of a material or tissue to conduct
heat
Tissues with high water content  better thermal
conductivity (e.g. muscles)
Adipose (fat) = insulator
4. Type of cooling agent
Ice Packs  greater temperature change compared to cold-
water baths or cold packs
(The energy is used to melt the ice before raising its
temperature)

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Evaporation
 By Vapocoolant sprays (e.g. Fluori-
Methane): Volatile liquids
 Liquid evaporates as it comes out of the
bottle – extracts heat upon contact with the
skin
 Temperature drop at the skin only

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 Indications for Cryotherapy
 Acute injuries
 Acute or chronic pain
 Prior to rehabilitation exercises
 Muscle spasm
 After physical activity

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Contraindications for Cryotherapy

 Cold allergies
– wheals, hives, joint pain, nausea, itching
 Cardiac or respiratory problems
 Circulatory insufficiency
 Anesthetic skin
 Previously frostbitten skin
 Some rheumatoid conditions
 Raynaud’s phenomenon
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Contraindications
 Cold-sensitivity symptoms:
– Cold urticaria: hypersensitivity; local = local redness & swelling;
wheals (erythema, raised borders, blanched centres); systemic =
flushing of face, BP, pulse rate, syncope
– Cryoglobinemia: abnormal blood protein that forms a precipitate or gel
at low temperatures  ischemia or gangrene (e.g. multiple myeloma,
leukemia, SLE, RA
– Cold intolerance: severe pain, numbness, colour change (redness,
cyanosis, mottling) e.g. rheumatic diseases, crush injuries, extremity-
replantation surgery
– Raynaud’s phenomenon: vasospastic disorder, attacks of cyanosis,
blanching, or rubor (pain, swelling, redness, heat), numbness of distal
parts precipitated by cold exposure or emotional stress. Idiopatheic or
associated with rheumatic diseases (e.g. scleroderma, SLE)
– Paroxysmal cold hemoglobinurias: following local or general exposure
to cold haemoglobin released from RBC and appears in urine

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Contraindications
 Peripheral vascular diseases; wounds;
prolonged application on superficial peripheral
nerves; psychological response
 Cardiac or respiratory problems
 History of frostbite

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 Sensations of Treatment
 Cold
 Stinging, Burning
 Aching
 Numbness
– onset at approx. 10-15 min.

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 Physiological Effects
 Vasoconstriction
Cold Modality Stimulation of local sensory receptors
Triggers response in Sympathetic nervous system
Increases smooth muscle tone Decreases blood vessel
diameter

 Hunting Response(??)

– Cold-Induced Vasodilation (Knight)

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 Physiological Effects
1.Hemodynamic effect (effect on
vascular bed)

 Cold application an immediate

constriction of the cutaneous blood
vessels in blood flow.
a) Initial decrease in blood flow
If cold is applied to the skin, it causes an
immediate constriction of the cutaneous
vessels and a reduction in blood flow.
This vasoconstriction persists as long as
the duration of the cold application is
limited to less thanRHS,327
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15 to 20 minutes. 16
 Mechanism of vasoconstriction
·Direct reflex activation of smooth muscles of blood
vessels by cutaneous cold receptors.
·Indirect : by decreasing the production and release of
vasodilator mediator, such as histamine and
prostaglandins, resulting in reduced vasodilatation.
Decreased the tissue temperature also cause reflex
activation of sympathetic adrenergic neurons
vasoconstriction
 Cold reduce the circulatory rate by increasing blood
viscosity Increasing the resistance to flow.

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b)Later increase in blood flow

 When cold is applied for longer period

of time or when tissue temperature
reaches less than 10ºC (50ºF)
vasodilatation This phenomenon is
known as cold-induced vasodilatation
(CIVD).

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Hunting response:
Following the application of intense cold to the
body vasoconstriction with liberation of
histamine- like (H) substance produced by
the intense cold and noxious stimuli.
sufficient H substances vasodilatation
occurred for about 4 to 6 minutes
remove all H substance
vasoconstriction was established again, with
vasodilatation occurring at further intervals
of 15 to 30 minutes.
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 The sudden vasodilation due to
intense cold application is termed
the (hunting response).
 The initial vasoconstrication lasts
about 9 to 16 minutes.
 lewis also stated that the after-
effect following removed of intense
cold for a prolonged period was
vasodilation which increased for 20
minutes then subsided slowly.

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2.Neuromuscular effects (on muscles and
nerve)
1)On muscle:
a) Altered muscle strength: depending on the
duration of the treatment and the time of
measurements, of cryotherapy has been
associated with both decrease and increase in
muscle strength.
 Isometric muscle strength increase directly
after the application of ice massage for 5
minutes or less due to facilitation of motor
nerve excitability and an increased
psychological motivation to perform.
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 In contrast after cooling for 30
minutes isometric muscle strength
decreased and then increased an
hour later, to reach greater than
pre-cooling strength for the
following 3 hours or longer.
The proposed mechanism:
prolonged cooling reduction
of blood flow to the muscles, slowed
motor nerve conduction, increased
muscle viscosity and increased joint
or soft tissue stiffness.
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b) Decreased spasticity:
cold can temporarily decrease
spasticity
Two mechanisms are involved:
first, a decrease in gamma
motor neuron activity and
later a decrease in afferent
spindle and Golgi tendon organ
activity.

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c) Facilitation of muscle
contraction:
brief application of
cryotherapy facilitate
alpha motor neuron activity
to produce a contraction in a
muscle that is flaccid due to
upper neuron dysfunction

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2) On nerve
 Analgesia due to de-sensitivity of
nerves:
 local cold application has numbing,
analgesic or anesthetic effect. This
has been used for the relief of
certain types of acute pain, such as
acute joint pain, pain of acute
bursitis, sprains and other acute
trauma and burn pain.
 Prolonged exposure damage
to the nerve mayRHS,327
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be result. 25
 Physiological Effects .
 Decrease Pain
– Cold over whole ms the SG - non-pain stimulus
– Decreases nerve conduction velocity - small
diameter, myelinated nerves affected first
– Decreases excitability of free nerve endings
(increase threshold of sensory receptors)
– Reduces mechanical pressure on nerves by
decreasing spasm and swelling

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3.Metabolic effects
 Cold decrease the rate of all metabolic
reactions, including those involved in
inflammation and healing. Thus
Cryotherapy can be used to control
acute inflammation.

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 Physiological Effects .
 Decrease Metabolism
– decrease heat production
– decrease production of metabolites
– decrease need for Oxygen (Hypoxia)
 Estimate if decrease temp. 10oC,
metabolism decreases 50%

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 Physiological Effects
 Decrease Temperature
– causes decrease in metabolism
– can penetrate 4 cm.
– Temp. change dependent on:
» temperature gradient
» time of exposure
» Thermo-conductivity of tissues
» type of cooling agent
– Direct relationship between change in temp. of skin and
underlying tissues
– Takes time to return to normal temp.

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 Physiological Effects .
 Decrease Inflammation
– The result of all the other effects

 Increase joint stiffness

– Increase viscosity of synovial fluid
– Decrease tissue elasticity

 Decrease Strength & Proprioception

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 Physiological Effects.
 Decreases Spasm
– Increases threshold of muscle spindles & golgi tendon
organs - causes relaxation
– Decreases pain

 Decreases Swelling
– Decrease capillary permeability
– Increase viscosity of blood
– Compression & elevation most effective for decreasing
swelling
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Effects on Oedema & Inflammation

 Cold application for the first 24 – 48 hours

following injury:
– Less fluid filtration into the interstitium due to
vasoconstriction
– Less inflammation
– Less pain
– Decrease in metabolic rate

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Effects on Peripheral Nerves
 Cold  in sensory and motor-conduction
velocities
 Quantity of change depends on duration and
degree of temperature alteration
 Most sensitive fibres: small-diameter
myelinated fibres
 Least responsive fibres: unmyelinated,
small-diameter fibers
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Methods
 Cold packs
 Ice massage
 Ice towels
 Cold baths
 Vapocoolant Sprays

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 Cryokinetics and cryostrech
 Cryokinetics is a technique that
combines the use of cold and
exercise in the treatment of
pathology or disease.
 Cryostrech is the application of
cooling agent before stretching. to
reduce muscle spasm and thus
allow greater R.O.M increase with
stretching.

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Factors affecting the physiological
effects of heat and cold
1. Water temperature
2. Difference between the
temperature of water and the skin,
i.e if one hand is placed in hot
water and the other in cold water,
then both in warm water, there
will be a sensation of hot to the
hand that was first in cold water.
3. Suddenness of application (rapid
or slow)
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4. Mechanical impact of water,
i.e. showers, sprays.
5. Surface area to be treated
(the larger the area the more
receptors stimulated and the
greater the physiological
effects).
6. Age and general heath of the
patients
7. Duration and frequency of the
treatment
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 Cryotherapy Modalities

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Methods
 Cold packs
 Ice massage
 Ice towels
 Cold baths
 Vapocoolant Sprays

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 Ice Bag
 Best for acute injuries
– WHY?
 Types of ice - cubed vs. crushed
 Application
– Tie bag close to ice
– Remove air
– Place bag directly on skin
– Treatment time: 15-20 min
 Precaution - superficial nerves
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 Cold Hydrocollator Packs
 Cooled to 8 degrees
 Application
– Do not place directly on skin - wrap in wet towels
– Treatment time: 15-20 min.

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 Instant / Reusable Cold Packs
 Chemical reaction causes the cold
– much colder than ice
 Be careful of leaks - contents can burn skin
 Application
– Do not place directly on skin - wrap in wet or
dry towels
– Treatment time: 15-20 min.
 Precaution - check for frostbite
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 Ice Massage
 Not for acute injuries
– WHY?
 Useful for chronic injuries or muscle spasm
– use ice massage with stretching
 Stimulates A-beta fibers-decreases muscles
spindles
 Application
– massage over area
Treatment time: 10-15 min.
» or until skin is numb (7-10 min.)

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 Cold Whirlpool
 Water is a good supportive medium for
ROM ex. and adds resistance
 Turbine causes water movement -
massaging action (analgesia, sedation)
 Precautions:
– Gravity dependent position
– Clean whirlpool before and after use if athlete
has open wounds
– High blood pressure, heart problems
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 Cold Whirlpool cont.
 Application
– Turn whirlpool on & off when the athlete is out
of the pool
– Treatment time: 10-20 min.
– Temperature: 50-60oF
» as amount of surface area in the whirlpool increases
the temperature increases and the time decreases
– If concerned about swelling - use a wrap
– Use a toe cap
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 Ice Immersion
 Similar to CWP - lower temperature, no turbine
 Drop in tissue temp. greater than with other
modalities
 Application
– Fill bucket with ice & water
– Treatment time: 7-10 min.
– Temperature: <50oF
 Precautions
– Gravity dependent position
– Use toe cap or wrap
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 Cryokinetics
 What is it?

 Application
– apply ice until numb
– do AROM ex. until pain returns (3-5 min.)
– reapply ice until numbness returns (3-5 min.)
– repeat several times
 Benefits
– early ROM, increases phagocytosis, increases tensile
strength, decreases atrophy, reestablishes
neuromuscular functioning
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 Vapocoolant Sprays cont.

 Examples -
– Ethyl Chloride, Fluormethane (now banned)
 Is a counterirritant - stimulates A-beta fibers
– cools by evaporation, cause decrease skin temp.
but no change in subcutaneous tissue temp.
 Effective for muscle spasms and trigger points

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 Vapocoolant Sprays cont.
 Application
– Hold bottle 12 in. from skin at a 30-45o angle
– Place body part on stretch
– Spray
» in one direction - distal to proximal
» speed - 4in. per second
– Approximately 4 strokes - area should be covered but
not frosted
 Contraindications
– Allergy to spray
– Open wounds, Acute injuries, Around eyes or face
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 Contrast Bath
 Transition modality for sub acute injuries
 How does it work?
– “Pumping Action” - vasoconstriction & vasodilation
– Stimulates peripheral bloodflow - aids in lymphatic &
venous return
 Indications
– Ecchymosis removal
– Edema removal
– Subacute inflammation
 Contraindications
– Acute injury, Hypersensitivity to cold
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 Contrast Bath cont.
 Application
– Use ice bags/hot packs OR whirlpools
» whirlpool temps: hot: 14-108oF cold: 50-60oF
– Alternate between cold & heat
» best ratio not determined
» C-H-C-H-C
» H-C-H-C
» H-C-H-C-H
» time in each range from 1-5 min.

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 Intermittent Cold Compression
Units (Cryotemp)
 Device that combines cold and compression
 Enhance venous and lymphatic return
– External compression equalize pressure gradient
– Circumferential vs. Sequential compression

– Superior to ice bag with a wrap. Why???

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 Intermittent Cold Compression
Units (Cryotemp) cont.
 Indications
– Acute and subacute edema
– Acute injuries
 Contraindications
– Undiagnosed fracture
– Compartment syndrome
– Thrombophlebitis
– Skin Conditions

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 Intermittent Cold Compression
Units (Cryotemp) cont.
 Application
– Temperature: 50-55oF – Starkey
– ~40oF – Cryotemp
– Pressure – should not exceed diastolic BP
– UE: 40-60mmHG
– LE: 60-100mmHg
– On/Off time: at least 3:1 (on time:off time)
» Recommend 5:1 or 6:1
– Treatment time: 20 minutes
– Combine with Electrical Stim
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