CRYOTHERAPY

Dr Rachana M
• Cryotherapy or ice therapy is the application
of cold to the body tissues after injury. This
practice is as old as medicine itself.

• Nowadays, local cold application may be

applied by the use of various forms of ice or
frozen gel packs, or by evaporation of volatile
fluids from the skin. Often skin temperature is
reduced to 10 C°.
 Physical Principles
• When ice is applied to the skin, heat is conducted from the
skin to the ice in order to melt it.
• To change its state, ice requires considerable energy that is
known as latent heat of fusion.
• A specific amount of energy required to change the solid
form of a particular substance into a liquid, or the liquid into
a gas. This energy is called Latent Heat and is the energy
required to change of state.
• One gram of ice at 0ºC requires 336 Joules of energy to
convert it into 1 gram of water at 0ºC, whereas 1 gram of
water at 0ºC requires 155 joules of energy to convert it into 1
gram of water at 37ºC. Thus, for cooling the body tissues it is
better to use ice for treatment rather than water.
 Factors affecting heat loss
• Temperature changes in the tissues will depend on
both the rate and amount of heat energy removed.
• The colder the application the greater the heat loss
from the tissue.
• In general , water filled tissue, such as muscle, have a
high thermal conductivity compared to fat or skin. Thus
the cooling of deeper tissue depend on the nature of
overlying tissue.
• The amount of energy loss is clearly dependent on
length of time of cold application.
• Larger the area the more heat energy is lost.
 Physiological Effects of Cold Application

• Circulatory Response
• The initial skin reaction to cooling is an attempt to preserve
heat. It is accomplished by an initial vasoconstriction. This
haemostatic response has the effect of cooling of the body
part.
• After a short period of time, the duration depends on the
area involved, a vasodilatation follows with alternating
periods of constriction and dilatation. This reaction of
“hunting” for a mean point of circulation is called “Lewis’s
Hunting Reaction”.
• During the vasodilatation, the arteriovenous anastomosis is
closed, thus causing an increase blood flow through the
capillaries. This is beneficial in the treatment of swelling and
tissue damage.
Lewis’s hunting reaction

Hunting response A
reflex increase in
vasodilatation
that occurs in
response to cold
approximately 15
minutes
into the
treatment.
• The initial vasoconstriction is often used to limit the
extravasations of blood into the tissues following
injuries (e.g. sports injuries). Ice therapy is then
usually followed by some forms of compression
bandage.

• The alternate periods of vasoconstriction and

vasodilatation affect the capillary blood flow and it is
across the capillary membrane that tissue fluid can
be removed from the area and returned in the
systemic circulation. Increased circulation allows
more nutrients and repair substances into the
damaged areas.
• Thus ice therapy is very useful in removing
swelling and accelerating tissue repair. i.e. ice
cubes massage may be used to accelerate the
rate of repair of pressure sores.
• The reduced metabolic rate of cooled tissues
allows cooled muscle to contract many
more times before fatigue sets in.
 2. On metabolic rate

• The principal effect of cooling living tissue will be

to reduce its metabolic rate in accordance to
Van’t Hoff Law.
• It states that the rate of any chemical action that
can be affected is increased/decreased by a
temperature rise/fall.
• Metabolism being a series of chemical reactions
will decrease with a fall of temperature.
• The actual change is about one eighth for each
1˚C.
 3.Neural response/peripheral nervous system

• The skin contains primary thermal receptors. Cold receptors

are several times more numerous than warm receptors. The
cold receptors respond to cooling by a sustained discharge of
impulses, the rate of which increases with further cooling.
• The rate of conduction of nerve fibers in a mixed (motor and
sensory) peripheral nerve is reduced by cooling. The first
fibers affected by gradual cooling are the A fibers (myelinated)
and eventually at very low temperatures the B and C fibers
(non-myelinated) are affected.
• Synaptic transmission can also be delayed.
• This effect is helpful in treating pain and hypertonicity.
 4.On motor system
• Muscle strength is seen to diminish on cooling
the limb in water at 10-15 C probably
because of its effect on viscosity and
metabolic rate.
• But there are evidences that the strength
increases over the original value about an
hour or so after cooling has ceased.
 Excitatory Cold Mechanism

• When cold is applied in an appropriate way on the

skin, ice can be used to increase the excitatory bias
around the anterior horn cell.
• Combined with other forms of excitation
(brushing, tapping,…) and with the patients’
volitation, this can often produce contraction of an
inhibited muscle (only with intact peripheral nerve
supply).
• This effect can be used when muscle are inhibited
postoperatively or in the later stages of regeneration
of a mixed peripheral nerve
• These structures are fairly deep and it would take several
minutes to produce a sufficiently low temperature to affect
them.
• As it was clinically demonstrated that the reduction of spasm
and spasticity occurs within 30 seconds of ice application, the
reaction to cooling can only be at the superficial tissues at the
skin.
• The skin stimulus produced by cold must have an effect on the
general level of excitation and inhibition in the region of the
anterior horn cells.
• Once spasm and spasticity have been reduced, more long-
time treatment is given in order to sustain the condition. In
the case of spasm, active movements are used to break down
the vicious circle of pain-spasm-more pain- more spasm.
• With spasticity, the technique will depend upon the
preference of the physical therapist.
 Uses of Ice Therapy

• Reduces pain.
• Reduces spasticity.
• Reduces muscle spasm.
• Reduces swelling.
• Promote repair of the damaged tissues.
• Provide excitatory stimulus to inhibited
muscles.
• Used in strength training.
 Reduction of Pain

• Pain reduction is one of the major effects of ice application

which has been used for many years.
• The probable mechanism is that by the stimulation of cold
receptors, impulses will be send back which will pass into the
posterior root of the spinal cord. These impulses, arriving
through large diameter nerves, effectively block out any other
(pain) impulses attempting to access the spinal cord (pain gate
theory).
• This reduces the pain temporarily. For permanent pain
relief, positive physiotherapy (strengthening, mobilization) has
to be given during this period of transient pain relief.
 Reduction of Spasticity

• Spasticity is the pathological state of

increased muscle tone resulting from damage
to the upper motor neurons. The small
anterior horn cell from the higher control of
extrapyramidal system and fires
spontaneously at an increased rate. The net
result of this is ultimately to increase tone in
the extrafusal muscle fibers, when the
hypertonic spastic state appears.
• Spasm is a normal response to injury or pain
and is manifested as an increase in muscle
tone in a specific area with the apparent aim
of limiting movement and further damage.
However the amount of spasm is often
exceeding and the sustained contraction of
muscles will in turn start to produce
pain, often resulting then in more spasm.
• The mechanisms by which cold reduces
spasticity and spasm are probably:
• the reduced velocity of nerve
conduction.
• the depressed sensitivity of receptors such as
the muscle spindle.
 Indications
• Acute pain
• Chronic pain
• Acute swelling (controlling hemorrhage and edema)
• Myofascial trigger points
• Muscle guarding
• Muscle spasm
• Acute muscle strain
• Acute ligament sprain
• Acute contusion
• Bursitis
• Tenosynovitis
• Tendinitis
• Delayed onset muscle soreness
 Contraindication
s
1. Impaired circulation (i.e., Raynaud’s
phenomenon)
2. Peripheral vascular disease
3. Hypersensitivity to cold
4. Skin anesthesia
5. Open wounds or skin conditions (cold
whirlpools and contrast baths)
6. Infection
 Possible effects are due to…..
• The effects of cryotherapy seen are mainly
due to
• Reducution in muscle damage markers:
• Creatine kinase
• Lactate dehydrogenase
• Myoglobin
• Immune markers (leukocyte & neutrophils)

• Reduce muscle soreness rating

• Reduce muscle fatigue rating
 Techniques of Application of Cryotherapy

• The way which ice is applied will vary according to

the required effects.
• It may be applied in the following ways:
– Ice towels
– Ice packs
– Immersion
– Ice cube massage
– Cold compression units
– Ice spray
– Contrast bath
 Time of application of various tech.
• The time required for the sequence varies, but
several authors indicate cryotherapeutic effect
sequences occurs within 5–20minutes.
•After 12–15 minutes the hunting response is
sometimes demonstrated with intense cold (10°
C[50° F]). Thus, a minimum of 15 minutes are
necessary to achieve extreme analgesic effects
 Ice packs

•Simple cold packs

•Silica gel packs
•Endothermic
reaction /chemical
cold packs.
 Ice towel

•Wet towel is used

•Ice towel need to be
replaced after 2-3 min.
and total 20 min .of
treatment can be
given.
•Useful in treating
muscle and
allows movement
to be performed.
 Immersion

•Simple immersion
•Whirlpool immersion
 Ice cube massage

•Slow circular motion for 5-10 min. During

This time the patient will feel cold, burning
And then aching sensation before the part
Become numb.
•Short strokes should be given.
 Cold compression unit

Cold water is circulated in a sleeve which

Is put over the limb and part of it is inflamed
At intervals.
 Cold/ Ice sprays

•Ethyl chloride was originally used but

it is highly inflammable an thus posses
some risks.
•Fluorimethane is now used widely as
it is non inflammable.
•The liquid is sprayed on to the area
to be cooled in series of stroke of
about 5s each with a few seconds
interval between each.
•The nozzle is held at the angle of
45
or right angle from the skin surface.
 Dangers of cryotherapy
• Frost bite
• Nerve palsy
 PROFORMA FOR PATIENT ’S ASSESSMent

1. Receiving the patient: Good morning, I am a

Physiotherapist and going to treat you. Please,
cooperate with me during the treatment and
wait until I go through your case sheet.
2. 2. History taking or going through the case
sheet: – Name – Father’s and Mother’s name
– Age – Sex – Occupation – Address:
Correspondence and permanent
Chief complaints – History of present illness
– History of past illness
– Family history
– Social and occupational history
– Treatment history
– Prognosis of the treatment
–
Investigations:
1. Hematological tests
2. Radiological tests—X-rays, MRI scan, etc.
3. Checking for general contraindications: –
Hypertension – Deep X-ray and cobalt therapy
– Epileptic patients – Non cooperative patients –
Mentally retarded patients – Anemia – Very poor
general condition of the patient – Menstruation.
4. Checking for local contraindications: – Skin
condition – Wound – Tumor
5. Preparation of trays: Two test tubes: – One
with hot water – One with cold water. Towels
Pillows Sand bags. 6. Preparation of the cold pack
or cryotherapy unit. 7. Gaining the confidence of
the patient. 8. Positioning the patient: –
Comfortable with good support.
9. Preparation of the patient: – Explain (Remove
the clothing where the area is to be treated) –
Testing the skin sensation – Inspection of the part
to be treated – Palpation of the part to be
treated. 10. Application to the patient: –
Development of appropriate cold level – Duration
– Safety
11. Termination: – Inspection of the part
(Erythema) or cold burn – Palpating the part
(Pain). 12. Record about the patient condition: –
Duration of the treatment – Name – Address. 13.
Knowledge of dangers: – If cold burn occurs,
gently rub the part. 14. Knowledge of
contraindications. 15. Home instructions. 16.
General information.
 ANKLE SPRAIN

ANKLE SPRAIN One of the most frequent injured

structures in sports, particularly in basketball and
football.
Ankle sprain is the most common of all the
sprains.
Lateral ligament sprain accounts for 85% of all
ankle sprains.
Mechanism of injury: The sudden forceful
inversion, plantar flexion and adduction causes
lateral ligament sprain.
Lateral ligaments comprises of the following, e.g.
the anterior talofibular ligament, posterior
talofibular ligament and the calcaneofibular
ligament.
The sudden forceful inversion, plantar flexion and
adduction of these ligaments causes sprain.
Grades of Sprain
Grade 1 : Minimal pain and disability: weight
bearing not impaired
Grade 2 : Moderate pain and disability: weight
bearing difficult
Grade 3 : Severe swelling, no pain, discoloration,
no weight bearing possible, significant functional
loss.
Investigation: X-ray: AP, Lateral (to see any associated
fracture)
Treatment: PRICES P : Prevention from the injury R : Rest
(relative rest) to the part I : Icing (to prevent swelling
and pain) C : Compression (by crepe bandage) of the
part E : Elevation of the part S : Support
• Cryotherapy is used to prevent swelling and to
minimize pain. Ice bag or cold pack is used for at least
20 minutes.
• Swelling is minimized and further injury of the
ligament fibers by swelling is also reduced.
• Compression is followed by crepe bandage. Ice bag
can be used along with compression also.
• Initially ice can be used for a period of 24 hours, but
can be extended upto 72 hours (depending upon the
severity) following injury. Gradual exercises are
started after 72 hours of the injury. Once swelling
and pain subsides, partial weight bearing can be
started. When partial weight bearing is pain-free, full
weightbearing is allowed and early return to
activities is suggested.
 Reference
s
• Clayton’s electrotherapy,9 edition- Sarah
th

& Bazin- W.B Sunders.

• John low &Reed:
Electrotherapy Explained,Butterworth.
THANK YOU