Download CRYOTHERAPY / COLD THERAPY

CRYOTHERAPY / COLD
THERAPY
Sekar.L
Historical perspective
–Ancient Greeks and Romans.
–Late 1880’s, cold compresses
after surgery
–Early 1960’s, cold therapy
widely recognized by
healthcare as a result of
studies by Grant (1964) and
Hayden (1964). Military
studies.
Why Ice?
Mild cooling often used in
an effort to control:
Inflammation
Pain control
Reduce spasticity
INTRODUCTION
Cryotherapy refers to the use of local or
general body cooling for therapeutic
purposes.
Cooling the body surface is simply the
transfer of heat energy away from the
tissues.
The primary methods of cooling are;
CONDUCTION
CONVECTION
PHYSIOLOGICAL CHANGES OF
COOLING
1. ON CUTANEOUS BLOOD VESSELS:There is immediate vasoconstriction
of cutaneous blood vessels, shown by
the BLANCHING.
After some minutes the
vasoconstriction may give rise to a
marked vasodilatation (AXON REFLEX
MECHANISM) & being replaced by
another episode of vasoconstriction.
This alteration of vasoconstriction
& vasodilatation is called as
LEWIS HUNTING REACTION.(This
occurs because to protect the
tissues from damage to prolonged
cooling & relative ischemia)
2. ON MUSCLE BLOOD FLOW:The cooling provokes
vasoconstriction in all vascular
smooth muscles
Reduced Secondary Tissue Injury
Cryotherapy
Heat transfer
Decrease metabolic
activity
Decrease ATP demand
Decrease O2 demand
Increase tissue survival
3. ON METABOLIC RATE:Decrease in metabolic rate (Decrease
in oxygen uptake, so cooling does not
benefit the healing process)
4. ON THE PERIPHERAL NERVOUS
SYSTEM:It provides strong sensory stimulus
by stimulating the cold receptors. (It
decreases the nerve conduction
velocity of the peripheral nerves &
synaptic transmission can also be
5. ON THE MOTOR
SYSTEM:The muscle strength is
decreased by cooling.
The motor skills are
decreased, Decrease in
velocity of movement &
finger tapping speed.
SENSORY PERCEPTION
1. COOLING / CHILLING
2. BURNING
3. EXTREME PAIN /
INTOLERABLE PAIN(ACHING)
4. NUMBNESS
THERAPEUTIC EFFECTS OF COLD
 1. RECENT INJURIES / ACUTE INJURIES (OEDEMA
REDUCTION)
“RICES-S RULE”
 R – Rest
 I – Application of ice leads to – Immediate
vasoconstriction, Increased viscosity of blood,
Decreased blood flow, Metabolic rate & Chemical
irritants – Decrease in rate of inflammatory
response resulting in Decrease in oedema
formation.
 I – Immobilization
C – Compression
E – Application of appropriate
electrotherapy modalities & the
elevation of the part above the heart
level. (Gravity to assist in reduction
of swelling)
S – Shock treatment
S – Support the part with splint
2. PAIN – DIRECTLY BY ACTING ON
CONDUCTION OF PAIN RECEPTORS &
NEURONS, REDUCING THE VELOCITY &
NUMBER OF IMPULSES.(A-Beta & C – fiber
stimulation)
Pain gate mechanism & also may release
endorphins & encephalin
(Counter
irritant effect).
Finally – Analgesic effect.
3. REDUCTION OF MUSCLE SPASM –
Pain – spasm – pain cycle (Inter related)
4. REDUCTION OF MUSCLE SPASTICITY Cutaneous effect by Decrease in gamma motor
neuron activity. (Decreasing the muscle spindle
discharge)
 Changes in viscoelastic property – Intrafusal &
Extrafusal muscle fibers.
 5. CHRONIC INFLAMMATORY CONDITIONS (O.A,
CHRONIC R.A.) –
 Pain relieving effect & control of sub acute inflammatory changes.
6. CHRONIC OEDEMA & JOINT EFFUSIONDecreases intravascular fluid pressure via
decreasing blood flow, increased viscosity
7. Facilitation of Muscle static Contraction
 Brief application (few seconds) facilitates alpha
motor neuron activity.
Produces muscle contraction in flaccid
muscle. (CVA, SCI)
 Prolonged cold (few minutes) decreases force of
contraction – leading to weakness.
8. Prophylactically after exercise to decrease DOMS
Delayed Onset Muscle Soreness
 Due to muscle connective tissue damage
secondary to exercise
INDICATIONS
Musculoskeletal trauma
Edema/hemorrhage control &
analgesia
Pain
Muscle spasm
Spasticity
Adjunct in muscle re-education
Reduction in metabolic activity
Contraindications to Cryotherapy
Cold sensitivity Reynaud’s Phenomena
Cold Urticaria
Cold induced
Hemoglobinuria and
Cryoglobinaemia
• Compromised circulation
or sensation
• Cardiac diseases
• Emotional &
psychological features
Reynaud’s Phenomena:• It is condition often associated with connective
tissue disorder – digital arteries.
• It exhibits cycles of pallor, cyanosis, rubor &
normal color in the hands & feet in response to
cold.
• Numbness, tingling or burning may also occur.
Cold Urticaria:•
It is a very cold sensitive condition.
•
It is characterized by raised reddened areas.
•
The systemic response may include – facial
flushing, a drop in B.P., a increase in pulse rate
& syncope.
Cryoglobinaemia:• An abnormal protein is present in the blood, it can
form a precipitate at low temperatures blocking
blood vessels & thus causing local ischemia.
• It is not common, but can be found in association
with some of connective tissue disorders.
Hemoglobinuria:• It is characterized by the presence of blood in the
urine.
Compromised circulation or
sensation:• Cold application may lead to burns
Cardiac diseases:• Coronary thrombosis & anginal pain
have sometimes been provoked by
cold. (Since it put heart a greater
demand due to increased B.P.)
Emotional & psychological features:-
• This is more likely to
seen in elderly
patient’s, because the
control mechanism is
becoming less
efficient in old age.
Precautions:-
 Over superficial main branch of a nerve
 Over an open wound - delays healing
 Hypertension - can cause transient increases
in systolic or diastolic BP
Patients with poor sensation
Very young or very old
impaired temperature regulation,
ability to communicate
Adverse Effects
Tissue Death
Frost Bite
Nerve damage
Freezing of tissues
METHODS OF APPLICATION OF
CRYOTHERAPY
1. LOCAL IMMERSION METHOD (ICE BATH / COLD BATH)
2. ICE PACKS
3. COMMERCIAL COLD PACKS
4. ICE TOWELS
5. ICE MASSAGE
6. COLD COMPRESSION UNITS
7. EVAPORATING SPRAYS
LOCAL IMMERSION METHOD (ICE
BATH / COLD BATH)
 This is the simplest method of all.
 It involves placing the treatment part in a container (Plastic
or rubber best) of iced water (Not ice water submersion)– a
mixture of water from the cold tap & flaked ice.
 This method is primarily used for distal
extremities.(Hand, forearm, foot & leg)
 Immersion of the body part allows complete
conformity of the cooling to the skin.
 Initial cooling usually quite painful.
Assuring patient that subsequent bouts
and sessions will be much less painful.
Using a toe cap to minimize pain.
 At temperatures around 16 - 18˚C continuous
immersion can usually be tolerated for 15 – 20
min.
 At around 10˚C, continuous immersion is
uncomfortable, so that intermittent application is
usually given.
Once numb, body part can
be removed from
immersion and ROM
exercise can be performed
As pain returns reimmersion should take
place
Cycle can be repeated 3
times
ICE PACKS
These are a simple & effective method for
cooling tissues.
Flacked ice is folded into damp terry
toweling or put into bags (POLYTHENE
BAG) made of the same material & applied
directly to the skin.
They may be held in place by a plastic
sheet wrapped around the part & the
pack.
A further towel is
occasionally wrapped
outside the plastic to
decrease the heat gain to the
ice pack from the outside air.
Cooling of the skin is quite
rapid at the first.
These packs are quite
tolerable for some 20 min.
ICE PACKS
 Equipment:
 Plastic bag filled with ice cubes or crushed ice
 Technique:
 Fill bag with ice & seal well to prevent leakage
 Duration: 5-15 min
 Advantages:
 Can mold to part being Rx’d
 Disadvantages: Bag can leak
COMMERCIAL COLD PACKS
These are basically plastic, often vinyl
bags filled with a mixture of water & some
semi-gelled substance.
These packs will remain flexible & can be
molded to the part.
Silica gels are the most common.
It comes with various sizes & shapes like
hydrocollator packs.
The cold packs are placed in freezer
units & remain cold up to 15 – 20
min after removal from cooling unit.
These packs are initially at lower
temperature than ordinary ice packs
& potentially cool the skin very
rapidly.
They may be applied either directly
to the skin or can be used with a wet
towel depending on the desired
The cold packs confirm to the
irregular surface areas &
maintains a constant
temperature – may be
problematic.
The cold packs are reusable &
self contained.
The main advantage if these
packs seems to be convenience.
COMMERCIAL COLD PACKS
3 types:
Clinical type: durable plastic cover around silica
gel & stored in refrigerator tank
Home type: similar but smaller than clinical
type; purchased in pharmacies & stored in
freezer
Disposable type: activated by breaking inner
seal that mixes chemicals within
Equipment: stored in refrigeration tank
like one used for hot packs with temp
about 10 – 15 F
Technique:
Use wet, well wrung out towel next to
skin (wet towel hastens cooling of part
being Rx’d, because moisture increases
rate of thermal conductivity)
Duration: 10-15 min
Advantages:
reusable
Can be used immediately after injuries
such a as sprains or fractures
ICE TOWELS
 A terry towel is put into a mixture of flaked ice &
water & then wrung out, much of the clipped ice
will be found to adhere to the cloth.
 This can be placed over a large area to give
immediate surface cooling.
 The ice towel will need to be replaced by another
one after 2 – 3 min.
 It is particularly useful method for the treatment
of muscles & allows movement or exercise to be
performed while cold therapy is being applied.
ICE TOWELS
 Technique:
 Towels thoroughly soaked in water & ice mixture
 Towel wrung out & applied to part; Procedure
repeated every few min
 Duration: 10-15 min
 Advantages:
 Equipment required is available almost anywhere
 Disadvantages:
 Therapist must keep changing towels
ICE MASSAGE / LOLLIPOP METHOD
 This is the application of ice directly onto the skin
surface.
 It is an intense cold application & usually applied
to small areas (Muscle belly or Trigger point)
 Either paper or Styrofoam cups or an ice lollipop
on a wooden stick is placed in the freezer.
 The use of paper or Styrofoam cups or wooden
stick provide insulation to the therapist handling
the ice.
 Being larger, the lollipop lasts longer & is easier
to handle than the usual size of ice cube.
 Ice massage produce a counter irritant effect.
 Two distinct purpose of ice massage:-
1.Pain relief – The ice block is moved over the part
using a slow circular motion for 5 – 10min.
2.Neurological facilitation – The ice should be
applied only brief, short strokes. The application
should be over the dermatome supplied by the
same nerve roots as those of the muscle that is to
be stimulated. (The fusimotor fibers of the
Adding a plate weight will increase
numbness.
Ice massage
Stroking of ice on body part to
numb skin
Equipment:
Ice that is frozen in insulated cup
“Lollipop”: Ice in cup with small
tongue depressor frozen in middle
Ice cube wrapped in paper towels
or washcloth
Technique:
Sensation = cold, burning, aching, numbness
Part being Rx’d may become pale & eventually
red
Ice should be applied in circular, smooth,
rhythmical strokes
Duration: 3-10 min
Advantages
Numbs skin easily in short time
Ice colder than chemical cold packs
Ice readily available
Disadvantages: ice may cause frostbite
COLD COMPRESSION UNITS
Cold therapy combined
with intermittent
compression devices to a
limb segment.
Cold water is circulated in
a sleeve which is put over
the limb & treatment part
COLD COMPRESSION UNITS
Vapocoolant / Evaporating Sprays
Spraying a rapidly evaporating liquid on the
skin has the effect of using heat energy &
hence cooling the surface.
Fluori-methane, non-flammable substance that
is released in fine spray from pressurized
canister.
The nozzle of the spray is held about 45cm
from the skin surface & close to a right angle.
Apply spray about 5sec with a few seconds
interval between them for 2 – 3 times.
Vapocoolant / Evaporating Sprays
 Method of cooling the skin by the evaporation
of a substance sprayed on the skin
 Equipment: Fluori-Methane
 Liquid begins to evaporate & continues to
evaporate when contacts skin, thus cooling skin
briefly
 Technique
 Expose area to be Rx’s
 Eyes should be protected
 Hold bottle in an inverted position at a 30 angle, 18
inches away at a rate of 4 inches per sec.
Duration Spraying should not
exceed 6 sec
Advantages:
Immediate reduction of pain
Can use on joint sprains to
relieve pain & swelling
Can use on thermal burns to
decrease pain, erythema, &
blistering
Cryokinetics
Technique that combines Cryotherapy with
exercise
Goal is to numb region to point of analgesia
and work towards achieving normal ROM
Equipment
Treat area with ice pack, massage or immersion
Application
When analgesia is experienced, exercises should be
performed.
 As pain returns, process may be repeated
Sequence can be repeated 5 times
Exercises should be pain free
Changes in intensity should be limited by both healing
and patient’s perception of pain
• Cold decreases pain, which
Facilitates active exercise
• Exercise
Reduces swelling
(dramatically) through
muscular milking action
Promotes healing and return
to function
Reduces inhibition
Cryostretch
•Combination of the muscle
spasm reduction techniques
Cold application
Static stretching
Hold–relax technique of PNF
Ice decreases pain and muscle
spasm.
Static stretching overcomes
stretch reflex, thus decreasing
muscle spasm.
Relaxation after maximal
muscular contraction is
greater than before
Clinical Parameters Taught in
PT School
Ice Bath 13°C to 18°C 10 to 30 minutes
Ice Towel 0°C 5 to 15 minutes
Ice Pack 0°C 5 to 15 minutes
Commercial Cold Pack -12.2°C to –9.4°C
10 to 15 minutes
Ice Massage 0°C 3 to 10 minutes