Cryotherapy

By Dr Ruchika gupta

Applying cold therapy will cause:

the skin temperature can be changed abruptly. the deeper tissues are cooled more slowly.
it takes some 30 min to lower the muscle temperature at a depth of 4 cm by 3.5C Muscle tissue at 2.5 cm can take up to 20 min or longer to drop 5C

When apply cold over thin subcutaneous fat layer for example knee joint
the intra-articular temperature of the knee joint fell by an average of 9.4C due to the application of ice bag for 30 min to the front of the knee.

Physiologically what happens when we use cold modalities to manage acute trauma?
Hemodynamic Effects Cellular Metabolism Effects Neurological Effects Neuromuscular Effects

Strength Spasm Neuromuscular control

Hemodynamic Effects

Immediate Response
Vasoconstriction @ arterioles and venules

Causes of Vasoconstriction
Direct action on smooth muscles Decrease the production/ release of vasodilators mediators such as Histamine & Prostaglandins. Reflexive cutaneous vasoconstriction

Hunting Reflex
Describes switching VD and VC Have VD but overall maintain VC state

Cellular Metabolism Affects

Secondary Hypoxic (Ischemic) Injury

Decrease oxygen Inadequate fuel substrates Inadequate waste removal

Attempt to reduce Secondary Injury

Cellular Response

Cold application decreases need for O2 at the injury site Decreased need for O2 results in a decrease in secondary cell death Decrease in secondary cell death causes a smaller amount of inflammatory substances to be released. Decreased cellular metabolism 20 minute of ice application decrease metabolism approx. 20% (Ho et. al. 1995)

Reduced Secondary Tissue Injury

Cryotherapy Heat transfer

Decrease metabolic activity

Decrease ATP demand

Decrease O2 demand

Increase tissue survival

Merrick, MSSE, 1999

Neurological Effects (Peripheral Nerves)

Alters conduction velocities

Decrease sensory Decrease motor conduction velocities Impeded or blocked synaptic transmission Sensory fibers affected first?
A-delta and C fibers Conduction velocities decreased Larger A fiber (alpha and beta affected last) Gamma motor neurons also affected Lager A fibers and gamma motor neuron important in reducing spasm

Why do we use cryotherapy?

Local Effects of Cold Modalities

Vasoconstriction Decreased cellular metabolism Decreased cellular waste production Reduction in inflammation Decreased pain Decreased muscle spasm

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Pain Control Reduce Secondary Tissue Injury

Pain Control

Gate Control
What afferent fiber?

Conduction Velocities
Pain sensory fibers
Lee et al, Physiother, 1978

Gamma motor neurons

Pain Control cold affects pain perception by: interrupting pain transmission decreasing nerve conduction velocity reducing muscle spasm limiting edema

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Control Inflammation
Cold suppresses inflammatory response: reducing the release of inflammatory mediators decreasing prostaglandin synthesis decreasing capillary permeability degree of hemorrhaging and edema are reduced by limiting inflammatory mediators Pain is decreased by lessening the mechanical pressure on nerves.

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Reducing Spasm
Muscle spindles and GTOs not work properly. Group Ia and II fibers reduce frequency of discharge. Alpha motorneuron firing decreases. End result Decreased stretch reflex sensitivity Decrease pain by reducing the threshold of afferent nerve endings. Decreases the sensitivity of muscle spindles. 9 F drop will reduce muscle spindle sensitivity

PHYSIOLOGICAL CHANGES

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PHYSIOLOGICAL CHANGES DUE TO COOLING THE SKIN

Applying cold therapy to the skin will cause hunting reaction

a dramatic vasoconstriction leads to decrease in blood flow through the skin And increased the blood viscosity which contribute to the slowed blood flow.

After some minutes the vasoconstriction may give way to a marked vasodilatation before being replaced by another episode of vasoconstriction. It occurs rapidly in the face, especially the nose and ears, but also in the hands, feet, patella region, olecranon, buttocks and some parts of the chest wall.
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Hunting Respose

This is a protection response to the tissues from damage due to prolonged cooling and relative ischaemia. It depend on the region especially the regions that normally exposed to pressure such as buttocks, anterior surface of knees and particularly the feet. This response is variable from person to person. It tends to occur about 5-15 min after cold. The arteriovenous anastomoses in the skin play a predominant role.

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The cause of this vasodilatation is still not completely elucidated, but it could be due to: axon reflex mechanism
involving a histamine-like substance (substance H) to cause local vasodilatation. As the increased blood flow washes out this substance the vessels constrict again thus continuing the cycle.

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On metabolic rate
The principal effect of cooling living tissue will be to reduce its metabolic rate. It will reduced oxygen uptake
the erythema due to cold-induced vasodilation is distinguished from that due to heating due to its pinkness because it contains less reduced haemoglobin.

Thus cooling does not benefit the healing process.

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peripheral nervous system

Cold application to the skin provides a strong sensory stimulus to cold receptors.
May suppress pain

reduces the conduction velocity of peripheral nerves (motor and sensory) and delays synaptic transmission.
Decrease hypertonicity

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Recent injuries

Reduce bleeding
Superficial bleeding (cooling must not be intense or so prolonged as to delay blood coagulation). deep bleeding (haematoma) needs long time cold application.

Cutaneous heat burns

requires rapid cooling of the area, lowers the tissue temperature and thus limits tissue damage.
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Soft tissues injury

Cooling will diminish the rate of swelling and production of irritants and so alleviate the pain. It part of PRICE technique (protection, rest, ice, compression and elevation).

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Relief Pain
It could be due to: Reducing edema
Less pressure and reduce irritant substances release.

Pain conduction
Reduces the velocity and number of impulses of the pain receptors and neurons.

Releasing of endorphins and encephalins

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Relief Muscle spasm

Muscle spasm is linked to pain There is therefore a reasonable expectation that the application of cold would reduce muscle spasm and so allow an increased range of movement.

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Spasticity

Brief contact is used therapeutically to facilitate muscle contraction

briefly stroking with ice cube over the appropriate dermatome,
for example. Ice stroking over the biceps for 12 min has been shown to enhance the motor unit activity of subjects

Cutaneous contact

diminishing gamma motor neuron activity or at least in some way diminishing the muscle spindle discharge, and reducing spasticity.

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Muscle strengthening

Some studies reported that ice application will increase the isometric strength. Others reported that ice application will decrease the muscle strength. These contradictory findings may thus be reflecting a difference in the degree of cooling in different investigations,
the shorter applications stimulating the nervous system, while prolonged intensive cooling affects muscle metabolism leading to
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Chronic inflammatory conditions

Degenerative and chronic joint diseases have been treated successfully with cold therapy, including osteoarthrosis and chronic rheumatoid arthritis.
pain-relieving effect control such minor acute or subacute inflammatory changes as occur from time to time with degenerative joint conditions.
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Chronic oedema and joint effusions

Reduce chronic oedema like in stroke patients. It could be do to

Hunting response Vasoconstriction (acute)

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Cryotherapy - Indications
Acute injury or inflammation Acute or chronic pain Small, superficial first degree burns Post surgical pain, and edema Use in conjunction with rehab exercises Acute or chronic muscle spasm Neuralgia

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Indications
Cold is indicated under three conditions: In the acute stages of the inflammatory reaction Before range-of-motion exercises After physical activity highly motivated patients (athletes) often return quickly to activity (before full healing) cold is often used for an extended time period when compared to the general population
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Cryotherapy Contraindications
Cardiac or respiratory involvement Uncovered open wounds Circulatory insufficiency Cold allergy Anaesthetic skin Advanced diabetes Raynauds phenomenon Hypersensitivity -hives

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Contraindications

Raynauds Phenomenon- A vascular reaction (usually benign) to cold application that results in white, red, or blue discoloration of the extremities (fingers and toes). thromboangiitis obliterans (Buergers disease) Presence of abnormal protein (Cryoglobinaemia) (systemic lupus erythematosus and rheumatoid arthritis) Cold urticaria. Cold causes the release of histamine from mast cells leading to a local weal and erythema and sometimes general (systemic) symptoms such as lowered blood pressure and raised pulse rate. Cardiac disease Coronary thrombosis and anginal pain have sometimes been provoked (may induce vasoconstriction). Arterial blood pressure (high blood pressure) When immerse large area could increase the blood pressure.
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METHODS OF APPLYING COLD THERAPY

Explain to the patient Prepare the patient.

Preparation of part. A suitable position depending on whether it is to be immersed or have a pack applied. The need for elevation and relaxation.

Instructions for the patient.

increased pain or discomfort.

Application.
check the application every few minutes and inspect the skin at the same time.

Termination.
the skin is dried and inspected.
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Local immersion

It involves placing the part in a container of iced water a mixture of water from the cold tap and flaked ice. At temperatures around 1618C continuous immersion can usually be tolerated for 1520 min. At lower temperatures, such as around 10C, continuous immersion is uncomfortable
intermittent application is usually given (1 min).

Used for hand, forearm, foot and leg.

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Cold packs
Ice packs Flaked ice is folded into damp terry-towelling or put into bags made of the same material and applied directly to the skin. Danger of ice burn Used for 20 min Commercial cold packs These are basically plastic, often vinyl, bags filled with a mixture of water and some substance such as Silica gels are the most common. The pack will be stored at a temperature below 0C, often 5C or even 12C. Applied over a wet towel for 20 min.
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Ice massage

solid piece of ice, either as an ice cube wrapped in paper or cloth or an ice lollipop on a wooden stick There are two distinct purposes for ice massage:
For the relief of pain, the ice block is moved over the part using a slow circular motion for some 510 min. For neurological facilitation the ice should be applied only briefly, either dabbing for about 4 s at a time or short strokes.
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Cold-compression units

Cold therapy combined with intermittent compression devices to a limb segment are available. Cold water is circulated in a sleeve which is put over the limb and part of it is inflated at intervals.

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Evaporating sprays
Spraying a rapidly evaporating liquid on the skin has the effect of using heat energy and hence cooling the surface. Ethyl chloride or fluorimethane (nonflammable) The liquid is sprayed on to the area to be cooled in a series of short strokes of about 5 s each with a few seconds interval between each. The nozzle of the spray is held about 45 cm from the skin surface and close to a right angle.

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