cryotherapy

 DEFINITION:
 Treatment under low temp called cryotherapy.
 Tissue can be cooled for therapeutic reasons variations can be attributed to :-
 Different methods of application.
 The length of time over which cooling has been applied.
 The initial temperature of techniques used eg: water temperature.
 EFFECTS ON TISSUE:
 Skin temperature: Different methods of application changes different in
temperature.
 Immersion in Water: Drop of 29.5 at a temp of 4c°after 193 mins.
 Ice massage: Drop of 26.6 at an ice temperature of 2 C° after 10 minutes .
 Evaporating sprays: A drop to b/w 15- 20 with sprays for 3 seconds at 15 cm
( using dimethyl ether).
 Ice packs: A drop of 20.3 ar a contact temperature of 0.3 C° after 10 minutes.
 Ice towels: A drop of 13c° after a 7 min period with repeated application of
towel.

 JOINT TEMPERATURE:
 Limited cooling of muscle when isolated by adipose tissue it is important to note that
joint cooling will be very limited is most especially deeper joint.
 PHYSIOLOGICAL EFFECTS:
 Effects on cell function.
 Circulation .
 Reduce blood flow.
 Hemorrhage.
 Pain
 Spasm , Muscle and tissue repair.
 During application of cold therapy the subject will experience a number of sensation
these may include:
 1) Intense cold.
 2) Burn sensation.
 3) Aching
 4) Analgesia

 COLD PACKS:
 Cold pack can be made by wrapping flaked ice in drmo terry towel .
 Applied for 20 mins.
 Rate of initial cooling rapid.
 Mc Master etal ( 1978) demonstrate that chemical packs are more effective in lowering
subcutaneous temperature.
 COLD BATH:
 Place body parts in cold water or a mixture of ice and water.
 Temperature can be controlled by varying the ratio of ice and water.
 Lee et al ( 1978) suggest that temp of 16-18c° may be tolerated for 15 - 20 mins.
 VAPORIZING SPRAYS :
 Role of evaporation is producing cooling of skin.
 Result effective but short lived tissue cooling.
 15- 20c° after temperature decrease in temperature to around 15 to 20 c° can be produced
will be repeated applications. ( cocker 2004 , Collier 2004, graffin 1997)
 volatile liquid: dimethyl ether spray use on treated area.
 Short burst: Approximate 3 to 5 each burst.

 ICE MASSAGE:
 Produce analgesia .
 Use lollipops or blocks over a small area muscle belly or trigger points
 slow circular motion.
 Temperature donot drop to level below 15c° .
 Facilitate muscle activity.
 PRECAUTIONS:
 Open wounds, infected, tissue damage.
 Cardiac disease.
 Defective skin sensation.
 High and low bp.
 CONTRAINDICATIONS :
 Acute febrile illness.
 Vasospasm.
 Cold urticaria.
 Cryoglobememia

 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°.

A. 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

Physiotherapeutic Uses of the
Circulatory Effect:
 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

 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.

Neural response
 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.

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

B. 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.

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,

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.

 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,

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
 Excitatory cold ( quick ice)
 Ice spray
 Cold gel

D. Contraindications to Ice
Treatment:
 Cardiac Conditions
 Psychological:
 Peripheral Nerve Injuries
 Vasospastic Disease
 Peripheral Vascular Disease
 Cold Sensitivity

Cryotherapy:
Physiologic Effects of Tissue
Cooling
 General agreement that cold should be initial
treatment for musculoskeletal injuries
 Primary reason is to lower temperature in injured area
 reduces metabolic rate with a corresponding
decrease in production of metabolites and metabolic
heat (secondary hypoxic response)
 More effective when combined with compression
 Promotes vasoconstriction and helps to control
hemorrhaging and edema

Cryotherapy:
Cooling
 Used immediately after injury to decrease pain and
muscle spasm
 Result of decreased nerve conduction velocity
 Cold stimulus bombards sensory receptors resulting in
pain modulation through gate control
 Effective in treating myofascial pain
 Effective in treating acute muscle pain as opposed
to delayed onset muscle soreness

Cryotherapy:
Cooling
 Reduction in muscle guarding has been observed
clinically
 Initial reaction of body to cold is local
vasoconstriction
 Results in decreased nutrient and phagocyte delivery to
area
 Hunting Response
 Periods of vasodilation and constriction following
prolonged cold application to limit possible tissue
injury due to cold use

Cryotherapy:
Cooling
 Cooling for too long may be detrimental to healing
 Ice application for 20 min. = decreased muscle
blood flow
 However, effects of ice application diminishes with
increased tissue depth
 Length of cooling required is dependent on
subcutaneous tissue thickness
 Recommended treatment times = 5-45 minutes

Cryotherapy:
Cooling
 Ability to lower tissue temperature is dependent
upon:
 Type of cold applied to the skin
 Thickness of subcutaneous fat
 Region of the body

Cryotherapy:
Cooling
 Cold application results in:
 Decreased cell permeability and metabolism
 Decreased edema accumulation
 Should be continued in 5-45 minute applications
for up to 72 hours initially

Cryotherapy Techniques
 Cryotherapy
techniques include
 Ice massage
 Cold packs
 Ice packs
 Cold whirlpool
 Cold spray
 Contrast baths
 Ice immersion
 Cryo-cuff
 Cryokinetics

Cryotherapy Techniques
 Application of cryotherapy produces a three- to
four-stage sensation
 Uncomfortable sensation of cold
 Stinging
 Burning or aching feeling
 Numbness
 Caution should be exercised when applying intense
cold directly to the skin

Ice Massage
 Often indicated with
conditions requiring
stretching
 Appears to cool area
faster than ice bag
application
 Procedures:
 Remove top 2/3 of
paper or styrofoam
cupleaving 1”on

Commercial Cold Packs
 Indicated for acute
musculoskeletal
injuries
 Procedures
 Cold pack should be
placed against
wet toweling and
covered with a towel
to limit environmental
warming
 Mold cold pack

Ice Packs
 Indicated for acute injuries and
prevention of swelling following
exercise of injured area
 Procedures:
 Flaked or cubed ice in a plastic bag large
enough for the area to be treated
 Applied directly to skin and held in place
by a moist or dry elastic wrap
 Can be molded to body part

Cold Whirlpool
 Indicated in acute and sub-acute situations where
exercise in cold environment is desired
 Must be mindful of gravity dependent position
 Procedures
 Fill appropriate size whirlpool with cold water and
flaked ice with temp. at 50° to 60° F
 Use for massaging action

 Most intense application of cryotherapy
 Inability to develop thermopane (insulating layer of water)
due to water turbulence
 Convection provides for continuous circulation of cold
water
 Results in significantly longer periods of temp. reduction
following treatment
 Additional care must be used with total body immersion
 With increased treatment area systemic effects are possible
 Equipment maintenance and cleaning are critical

Cold Spray and Stretch
 Flourimethane is used
 Acts as a counterirritant to block pain
 Cooling is superficial without significant penetration
 Useful in treating trigger points
 Not effective in treating edema or hemorrhaging
 Indicated in situations where cooling and stretching
are desired

 Procedure
 Spraying technique
 Same direction, even sweeps
 Work proximal to distal
 For trigger points, work from point to referred pain area
 Affected muscles should be sprayed from the affected area
to the insertion
 Static stretching can be incorporated as you spray

Contrast Baths
 Used to treat subacute swelling
 Does not reduce edema through “pumping”
action as suggested
 Uses alternating hot (104-106o) and cold (50-
60o) immersions
 3:1 or 4:1 heat:cold ratios have been
recommended
 Best used as a transition from cold to heat

Cold Compression Units:
Cryo-cuff
 Used both acutely
following injury and
post-surgically
 Applies both cold and
compression
simultaneously
 Ice chills water which
flows into sleeve from
cooler
 As cooler is raised

Cryokinetics
 Combines cryotherapy with exercise
 Goal is to numb injured part (12-20 min) then work
toward achieving normal ROM through progressive
active exercise
 Numbness usually last for 3-5 min. at which point
ice is reapplied for 3-5 minutes until numbness
returns
 Can be repeated five times
 Exercises should be pain free and progressive in
intensity concentrating on both flexibility and
strength

Ice Immersion
 Ice buckets allow ease
of application (50-
60o)
 Container should be
large enough to allow
for movement of body
segment if being used
for cryokinetics
 Body segment is
subject to gravity-

Warm Whirlpool
 Temperature Range
 Upper Extremity 98° -
110° F
 Lower Extremity 98-
104° F
 Full body 98° - 102°
F
 Time of application
should be 15 to 20
minutes

Warm Whirlpool
 Provides massaging effect and will stimulate
circulation
 Monitor for changes in edema
 Excellent post-surgical modality
 Increases systemic blood flow and mobilization of
body part
 Also noted to be one of the most abused clinical
modalities

Summary
Indications for Cryotherapy
 Acute or subacute
inflammation
 Acute pain
 Chronic pain
 Acute swelling
 Myofascial trigger
points
 Muscle guarding
 Muscle spasm
 Acute muscle strain
 Acute ligament sprain
 Acute contusion
 Bursitis
 Tenosynovitis
 Tendinitis
 Delayed onset muscle
soreness

Summary
Contraindications for
Cryotherapy
 Impaired circulation
 Peripheral vascular
disease
 Hypersensitivity to
cold
 Skin anesthesia
 Open wounds or skin
conditions (cold
whirlpools and
contrast baths)
 Infection


Physiology Basics
 Vasodilation
 Increased size of vascular structures
 Means more oxygen to the tissue
 Vasoconstriction
 Decreased size of vascular structures
 Useful for preserving compromised/injured cells/tissue

Physiology Basics
 Analgesia
 Diminished/reduced sensation
 Metabolic rate
 Activity level of cells
 Reducing MR can preserve cells damaged by injury
 Inflammation
 Series of events that hinder optimal function

Modalities
 Alter cell metabolism
 Each 1.8°F (1°C) change in tissue temp. results in a
13%  or  in the tissue’s metabolic rate.
 Energy absorbed by one tissue later can’t be
transmitted to deeper layers.
 Law of Grotthus-Draper
 The more energy absorbed by superficial tissues  the
amount absorbed by deeper tissue.

Cryotherapy – Cold Therapy
 Cold modalities range in temp. between 32°F-65°F
 Heat is removed from the body & absorbed by the
cold modality
 Tissue temperature is LOWERED
 To obtain therapeutic benefits, the skin temp. must
be lowered to approx. 57°F.
 Cold therapy applied is thought to activate a
mechanism used to conserve heat in the body’s core
 This mechanism triggers a series of metabolic &
vascular events that produce the beneficial effects of
cryotherapy.

Cryotherapy
 Normal skin temp. is approx. 91°F
 The deeper the tissue in the body, the higher the temp.
 Skin is cooler than adipose which is cooler than
muscular tissue.
 Thermoreceptors in skin are responsive to heat or
cold (more to cold than heat).

Sensations with Cold
Application
 Cold
 Burning
 Aching
 Analgesia (absence of pain)
  of n. conduction velocity &  threshold are required
to fire the nerve(s).

Cryotherapy Indications
 Acute injury or inflammation
 Pain
 Muscle spasm, acute or chronic
 Restoration of ROM
 Small, superficial, 1st degree burns
 Post-surgical pain & edema
 Neuralgia
 Post-exercise

Cryotherapy Contraindications
 Situations where the
body is unable to cope
with temp. change
because of allergy,
hypersensitivity, or
circulatory
insufficiency
 Cardiac or respiratory
involvement
 Uncovered open
wounds
 Circulatory
insufficiency
 Cold allergy
 Anesthetic skin
 Advanced diabetes
 Raynaud’s
phenomenon or other
Peripheral Vascular

Local Effects of Cryotherapy
  cell metabolism rate – PRIMARY BENEFIT
  need for oxygen
 Lowers tissue temperature
 Vasoconstriction
  production of cellular wastes
 Prevents or limits swelling
  in pain by  pain threshold
  in acute & chronic muscle spasm
 Limits area of original injury

 Deeper tissues cool more slowly & to a lesser
extent than skin
 Muscle tissue requires longer to cool than bony areas
 Deeper tissue temps. have been proven to drop for
several minutes following the removal of an ice pack
 Research has shown that deeper tissues remaining at
rest will be cooled for 2 hr or more after a 20- to 30-
min. ice pack application
 The cold modality will continue to remove body
heat until temps. are (=).

Precautions
 Take into consideration the amount of pain that
occurs during exercise after cold has been applied
 Be careful when applying an elastic wrap over a
cold pack over superficial nerves (Nerve Palsy)
 Uticaria – hives

Cellular Response
  cellular metabolic rate
 During a 20-min. treatment, cell metabolism  19%
 With  b. flow, there is less metabolic activity &
O2 demand on the cells
  need for O2
 Reduces number of cells killed by lack of O2
 Reduces secondary hypoxic injury damage
 Reduces amount of chemical mediators released in
area
 Slows nerve conduction

Vascular Responses
 Vasoconstriction occurs due to stimulation of n.
receptors
 Viscosity of blood & tissue fluids 
 Resistance to b. flow 
 Soft tissue  of 26% & skeletal b. flow  of 19% with
20-min. ice pack in injured ankles
 Amount of b. flow is still under debate
 Most studies indicate that b. flow 
 Because of effects associated with rubbing the skin,
IM may  b. flow, at least to the skin

Tissue Temperature Changes
 57°F skin temp. – optimal decrease in local blood
flow
 58°F skin temp. – analgesia occurs
 Temp. within the joint decreases proportionally to
temp. of skin overlying a joint decreases
 Temp. changes most rapidly in skin & synovium

Muscle Spasm
 Cold therapy affects pain threshold
  nerve conduction velocity by slowing
communication at the synapse
  pain by reducing the threshold of afferent n. endings.
  sensitivity of m. spindles
 May inhibit the stretch reflex mechanism reducing m.
spasm & breaking pain-spasm cycle

Inflammation
 Changes in cellular function & blood dynamics
serve to control effects of acute inflammation.
 Cold suppresses the inflammatory response by:
  the release of inflammatory mediators (histamine,
prostaglandin)
  prostaglandin synthesis
  capillary permeability
  leukocyte/endothelial interaction
  creatine-kinase activity

Pain Control
 Cold therapy acts as a counterirritant
 Cold application affects pain perception &
transmission by:
 Interrupting pain transmission (stimulates large-
diameter A-beta n. fibers)
 Decreasing n. conduction velocity
 Reducing m. spasm
 Reducing or limiting edema

Systemic Effects of Cold
Exposure
 If circulating blood temp.  0.2°F, then the
hypothalamus (body’s thermoregulatory center)
kicks in
 General vasoconstriction in response to cooling of
the posterior hypothalamus
 Decreased respiratory & heart rates
 Heart rate  (wants to localize the cold area)
 Shivering & increased muscle tone
 If heart rate  too much where the core temp. reaches
hypothermia

Application of Cryotherapy
 Ice Massage: Should not be applied during acute inflammatory stage as it’s not compatible
with compression
 5-15 mins. – reduces pain, desensitizes trigger points
 Vigorous Ice Massage
 Ice Pack: type of ice – cubed, flaked
 Commercial Cold Packs: chemical, reusable (Gel)
 Be aware of frostbite; use insulating layer in between
 Cryo-cuff/Polar Care: provide approx. 40 mm Hg
 Cold Water Immersion:
 Ice bucket: 40 °-50°F
 Whirlpool: 50 °-60°F
 Vapocoolant Spray: superficial, rapid cooling through evaporation; virtually no temperature
change below epidermis; will numb area briefly (trigger points)
 Intermittent Compression: Segmental compression with cold

Cryotherapy
 Duration usually15-30 mins. Don’t apply for more
than 60 minutes!
 Depends on skinfold thickness
 Ice with compression – affects deeper tissues
 Compression encourages  lymphatic drainage
 Circumferential: compression around entire area (ace wrap)
 Collateral: compression on both sides (aircast, gelcast)
 Focal: direct pressure to soft tissue surrounded by bony
structure (horseshoe)
 Cooling of tissue: rapid at first, then slows, then
levels off

Cryokinetics for Sub-Acute
Injury Stage
 Alternating cold therapy with exercise
 Use good judgment! Do not cause further harm!
 Place cryotherapy to body part for approx. 20 min.
(analgesia feeling)
 Remove cryotherapy & begin active exercise
 Place cryotherapy back on body part once
feeling/pain returns
 Repeat

Hunting Response
 1930’s ; Lewis performed skin studies with
temperature change during cold treatments.
 When the fingers were immersed in cold water,
alternating periods of cooling & warming were seen in
the skin.
 Thoughts were that intermittent cold-induced
vasodilation (CIVD) lasting 4-6 min. after
approximately 30 min. of cryotherapy application (p.
109)
 Stated that it prevented local tissue injury
 Today’s researchers state that CIVD does not occur
during standard cryotherapy sessions.

Cryotherapy (Ice)
 Application
 Ice massage
 7-10 minutes
 Excellent for muscle spasm and deep soreness

Cryotherapy (Ice)
 Application
 Ice bags, ice towels, or
cold packs
 15-20 minutes (no
longer than 30)
 If using packs, be sure
to avoid direct contact
to protect skin!
 Cold whirlpool / ice
immersion
 5-15 minutes, 55-65
degrees
 Duration and

cryotherapy

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