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COLD-CRYOTHERAPY

Cryotherapy, the therapeutic use of cold, has clinical applications in rehabilitation

EFFECTS OF COLD
Hemodynamic effects
Initial decrease in blood flow
Later increase in blood flow
Neuromuscular effects
Decreased nerve conduction velocity
Increased pain threshold
Altered muscle strength
Decreased spasticity
Facilitation of muscle contraction
Metabolic effects
Decreased metabolic rate
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Hemodynamic effects
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 (application is limited to less than 15 to 20 minutes)
Cold causes cutaneous vasoconstriction by both direct and indirect mechanism
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Later increase in blood flow

When cold is applied for longer periods of time (more than 15 min) or when the tissue
temperature reaches less than 10 0C vasodilation may occur. This phenomenon is
known as cold-induced vasodilation (CIVD) and was first reported by lewis in 1930.
Temperature cycling with alternating vasoconstriction and vasodilation and called is

lewis hunting response or lewis hunting reaction

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Cold-induced vasodilation is most likely to occur in the distal extremities, such as the
fingers or toes, with application of cold for more than 15 minutes at temperatures below 1
0C.
Cooling decreases oxygen-hemoglobin dissociation, making less oxygen available to the
tissues at lower temperature, cold induced vasodilation is not considered to be an
effective means of increasing oxygen delivery to an area.

Neuromuscular Effect
Decreasing Nerve Conduction Velocity,
Elevating The Pain Threshold,
Altering Muscle Force Generation
Decreasing Spasticity, And
Facilitating Muscle Contraction
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Decreased nerve conduction velocity

When the nerve temperature is decreased, nerve conduction velocity decreases in
proportion to the degree and duration of the temperature change
5 minutes or longer
The decrease in nerve conduction velocity that occurs with 5 minutes of cooling fully
reverses within 15 minutes in individuals with normal circulation
Cold can decrease the conduction velocity of both sensory and motor nerve
A-delta fibers, which are small-diameter, myelinated, pain-transmitting fibers,
demonstrate the greatest decrease in conduction velocity in response to cooling

 Altering Muscle Force Generation

Decreasing Spasticity, And
Facilitating Muscle Contraction

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Decreased nerve conduction velocity

When the nerve temperature is decreased, nerve conduction velocity decreases in
proportion to the degree and duration of the temperature change
5 minutes or longer
The decrease in nerve conduction velocity that occurs with 5 minutes of cooling fully
reverses within 15 minutes in individuals with normal circulation
Cold can decrease the conduction velocity of both sensory and motor nerve
A-delta fibers, which are small-diameter, myelinated, pain-transmitting fibers,
demonstrate the greatest decrease in conduction velocity in response to cooling
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Increased pain threshold

Application of Cryotherapy can increase the pain threshold and decrease the
sensation of pain
Mechanisms for these effects include
Counter-irritation via the gate control mechanism and the reduction of
Muscle spasm,
Sensory nerve conduction velocity, or
Post injury edema
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Altered muscle strength

Depending on the duration of treatment icing increases and decreases muscle
strength
Isometric muscle strength has been found to increase directly after the application
of ice massage for 5 minutes or less
Mechanism for this response to brief cooling includes facilitation of motor nerve
excitability and an increased psychological motivation
After cooling for 30 minutes or longer, isometric strength has been found to decrease
initially and to increase an hour later
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Mechanisms for the reduced strength after prolonged cooling include reduction of blood
flow to the muscles, slowed motor conduction, increased muscle viscosity, and joint or
soft tissue stiffness.

Effects of cold on strength of muscle contraction

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Decreased spasticity
Cryotherapy can temporarily decrease spasticity
Two mechanisms are proposed to act sequentially to produce this effect:
First, a decrease in gamma motor neuron activity and
Later, a decrease in afferent spindle and Golgi tendon Organ activity
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After more prolonged cooling, lasting for 10 to 30 minutes, a temporary decrease or

elimination of spasticity and clonus and a reduction in resistance to passive motion
These changes are thought to be caused by decrease in the discharge from the
afferent spindles and Golgi tendon organs as a result of decreased muscle temperature.
These later effects generally persist for 1 to 1.5 hours and can therefore be taken
advantage of in treatment by applying Cryotherapy to hypertonic areas for up to 30
minutes before other interventions, to reduce spasticity during functional or
therapeutic activities
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 First, a decrease in gamma motor neuron activity and

Later, a decrease in afferent spindle and Golgi tendon Organ activity
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After more prolonged cooling, lasting for 10 to 30 minutes, a temporary decrease or

elimination of spasticity and clonus and a reduction in resistance to passive motion
These changes are thought to be caused by decrease in the discharge from the
afferent spindles and Golgi tendon organs as a result of decreased muscle temperature.
These later effects generally persist for 1 to 1.5 hours and can therefore be taken
advantage of in treatment by applying Cryotherapy to hypertonic areas for up to 30
minutes before other interventions, to reduce spasticity during functional or
therapeutic activities
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Facilitation of muscle contraction

Brief application of Cryotherapy facilitates alpha motor neuron activity to produce a
contraction in a muscle that is flaccid due to upper motor neuron dysfunction
Metabolic effects
Decreased metabolic rate
Cold decreases the rate of all metabolic reactions, including those involved in
inflammation and healing
Cryotherapy is recommended as a treatment for the prevention or reduction of collagen
destruction in inflammatory joint diseases such as osteoarthritis and rheumatoid
arthritis
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TYPES OF COOLING AGENTS

1. Cold packs or ice packs
2. Ice cups for ice massage
3. Controlled cold compression units
4. Vapocoolant sprays or brief icing
5. Frozen towels
6. Ice water immersion
7. Cold whirlpool
8. Contrast bath

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USES OF CRYOTHERAPY
Inflammation control
Edema control
Pain control
Modification of spasticity
Symptom management in multiple sclerosis
Facilitation
Cry kinetics and cryostretch

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Inflammation Control
Decreasing tissue temperature slows the rate of the chemical reactions that occur
during the acute inflammatory response and also reduces the heat, redness, edema,
pain, and loss of function associated with this phase of tissue healing
The decrease in blood flow caused by vasoconstriction and increased blood viscosity, and
the decrease in capillary permeability associated with Cryotherapy, impede the
movement of fluid from the capillaries to the interstitial tissue, thereby controlling
bleeding and fluid loss after acute trauma.
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These effects reduce the redness and edema associated with inflammation control pain
by decreasing the activity of the A-delta pain fibers and by gating at the spinal cord
level

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Inflammation Control
Decreasing tissue temperature slows the rate of the chemical reactions that occur
during the acute inflammatory response and also reduces the heat, redness, edema,
pain, and loss of function associated with this phase of tissue healing
The decrease in blood flow caused by vasoconstriction and increased blood viscosity, and
the decrease in capillary permeability associated with Cryotherapy, impede the
movement of fluid from the capillaries to the interstitial tissue, thereby controlling
bleeding and fluid loss after acute trauma.

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These effects reduce the redness and edema associated with inflammation control pain
by decreasing the activity of the A-delta pain fibers and by gating at the spinal cord
level
Controlling the edema and pain associated with inflammation limits the loss of
function associated with this phase of tissue healing.
Cryotherapy after exercise reduce the severity of delayed-onset muscle soreness
(DOMS)
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DOMS is thought to be the result of inflammation from muscle and connective tissue
damage caused by exercise
Cryotherapy can effectively decrease post activity soreness
When Cryotherapy is applied with the goal of controlling inflammation, the treatment
time is generally limited to 15 minutes or less because longer application has been
associated with vasodilation and increased circulation
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Edema Control
During acute inflammation, edema is caused by extravasation of fluid in to the
interstitium caused by increased intravascular fluid pressure and increased vascular
permeability
Cryotherapy reduces the intravascular fluid pressure by reducing blood flow in to the
area via vasoconstriction and increased blood viscosity.
Cryotherapy also controls increases in capillary permeability by reducing the release of
vasoactive substances, such as histamine.
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The formation of edema associated with inflammation will be most effectively controlled
if the cryotherapy is applied in conjunction with compression and elevation of the
affected area
Cryotherapy is not effective in controlling the formation of edema caused by
immobility and poor circulation
This is best accomplished with compression, elevation, heat, exercise, and massage
Modification of Spasticity
Cryotherapy can be used to temporarily reduce spasticity in patients with upper
motor neuron dysfunction
Brief applications of cold, lasting for about 5 minutes, cause an almost immediate
decrease in deep tendon reflexes
Longer applications, for 10 to 30 minutes, also decrease or eliminate clonus and
decrease the resistance of muscles to passive stretch
Longer applications of cryotherapy control more of the signs of spasticity cryotherapy
should be applied for up to 30 minutes when this is the treatment goal
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Decrease in spasticity produced by prolonged cooling generally lasts for 1 hour or

longer after the treatment, which is sufficient to allow for a variety of therapeutic
interventions, including active exercise, stretching, functional activities.
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Pain Control
Decrease in tissue temperature produced by cryotherapy may directly or indirectly

 Longer applications, for 10 to 30 minutes, also decrease or eliminate clonus and

decrease the resistance of muscles to passive stretch
Longer applications of cryotherapy control more of the signs of spasticity cryotherapy
should be applied for up to 30 minutes when this is the treatment goal

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Decrease in spasticity produced by prolonged cooling generally lasts for 1 hour or

longer after the treatment, which is sufficient to allow for a variety of therapeutic
interventions, including active exercise, stretching, functional activities.
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Pain Control
Decrease in tissue temperature produced by cryotherapy may directly or indirectly
reduce the sensation of pain
Cryotherapy directly and rapidly modifies the sensation of pain by gating pain
transmission by activation of the cutaneous thermal receptors
Applying cryotherapy for 10 to 15 minutes or longer can control pain for 1 or more
hours. This prolonged effect is thought to be the result of blocking nerve conduction by
deep pain-transmitting a-delta fiber
Reduction of pain by cryotherapy can also interrupt the pain-spasm-pain cycle
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Facilitation
The rapid application of ice as a stimulus to elicit desired motor patterns, known as
quick icing a technique developed by Rood
Cryokinetics and Cryostretching
Cryokinetics is a technique that combines the use of cold and exercise
This technique involves applying a cooling agent to the point of numbness shortly after
any injury to reduce the sensation of pain and thus allow the patient to exercise and
work toward regaining range of motion
This approach is most commonly used in the rehabilitation of athlete
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Cold is applied first for up to 20 minutes, or until the patient reports numbing of the
area;
then the patient performs strengthening and stretching exercises for 3 to 5 minutes
until sensation returns
The cooling agent is then reapplied until analgesia is regained.
This sequence of cooling, exercise, and recooling is repeated approximately five times
Cryostretch is the application of a cooling agent before stretching. The purpose of this
sequence of treatments is to reduce muscle spasm and thus allow greater range-ofmotion increases with stretching
CONTRAINDICATIONS AND PRECAUTIONS FOR
CRYOTHERAPY
Cold Hypersensitivity (Cold-induced Urticaria).
This reaction is marked by the transient appearance of smooth, slightly elevated patches,
which are redder or more pale than the surrounding skin and are often attended by
severe itching
Cold intolerance
Cold intolerance. in the form severe pain, numbness, and color changes in to cold, can
occur in patients with some types of rheumatic diseases

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Cryo globulinemia
Cryoglobulinemia is an uncommon disorder characterized by the aggregation of serum
proteins in the distal circulation when the distal extremities are cooled
These aggregated proteins forms a precipitate or gel that can impair circulation
Paroxysmal Cold Hemoglobinuria
Paroxysmal cold hemoglobinuria is the release of hemoglobin into the urine from lysed
red blood cells in response to local or general exposure to cold
Raynaud's disease or phenomenon
characterized by sudden pallor and cyanosis followed by redness of the skin of the digits
precipitated by cold

occur in patients with some types of rheumatic diseases

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Cryo globulinemia
Cryoglobulinemia is an uncommon disorder characterized by the aggregation of serum
proteins in the distal circulation when the distal extremities are cooled
These aggregated proteins forms a precipitate or gel that can impair circulation
Paroxysmal Cold Hemoglobinuria
Paroxysmal cold hemoglobinuria is the release of hemoglobin into the urine from lysed
red blood cells in response to local or general exposure to cold
Raynaud's disease or phenomenon
characterized by sudden pallor and cyanosis followed by redness of the skin of the digits
precipitated by cold

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Over regenerating peripheral nerves

Cryotherapy should not be applied directly over a regenerating peripheral nerve because
local vasoconstriction or altered nerve conduction may delay nerve regeneration.
Over an area with circulatory compromise or peripheral vascular disease
Cryotherapy should not be applied over an area with impaired circular ion because it may
aggravate the condition by causing vasoconstriction and increasing blood viscosity
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PRECAUTIONS
Over the superficial main branch of a nerve
Applying cold directly over the superficial main branch of a nerve, such as the
peroneal nerve at the lateral knee or the radial nerve at the postero lateral elbow, may
cause a nerve conduction block.
Over an open wound
Cryotherapy should not be applied directly over any deep open wound because it can
delay wound healing by reducing circulation and metabolic rate
Hypertension
cold can cause transient increases in systolic diastolic blood pressure, patients with
hypertention should be carefully monitored during the application of cryotherapy
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In patients with poor sensation or poor mentation

The patient cannot sense or report discomfort and other abnormal responses, the
clinician should note for the patient's response directly
Very young and very old patient
Caution should be used when applying cryotherapy to the very young or the very old
because these individuals frequently have impaired thermal and a limited ability to
communicate.