Therapeutic Cold Applications

1. Cold Applications
Dr. Binu Babu
Ph.D, M.Sc. (N), MBA
Mrs. Jincy Ealias
M.Sc. (N)

2. • Application of heat and cold to the body can
be therapeutic, but before using these
therapies, the nurse must understand
normal body responses to application of
heat and cold and how and when to use

3. • Dry cold is generally applied locally by means of a
cold pack, ice bag, ice glove, or ice collar. In
addition, continuous cold therapy (cryotherapy)
following joint surgery or injury can be delivered
by a cooling unit similar to the aquathermia pad.
Moist cold can be provided by compress or a
cooling sponge bath.

4. Indications of Cold
Indication Effect of Cold
Muscle spasm Relaxes muscles and decreases muscle
contractility.
Inflammation Vasoconstriction decreases capillary permeability,
decreases blood flow, slows cellular metabolism.
Pain Decreases pain by slowing nerve conduction rate
and blocking nerve impulses; produces
numbness,
acts as a counterirritant, increases pain threshold.
Traumatic injury Decreases bleeding by constricting blood vessels;
decreases edema by reducing capillary
permeability.

5. • Cold application is the application of a cold
agent cooler than skin either in a moist or dry
form, on the surface of the skin
– To reduce pain and body temperature
– To anaesthetize an area
– To control hemorrhage
– To control the growth of bacteria
– To prevent gangrene
– To prevent edema
– To reduce inflammation.

6. Temperature for heat and cold applications
Description Temperature Application
Very Cold 320 to 550 F Ice bag
Cold 550 to 650F Cold packs
Cool 650 to 800 F Cold compress
Neutral 800 to 920F
Alcohol sponge
bath
Warm 920 to 980 F Warm bath
Hot 980 to 1040 F Hot soak
Very Hot more than 1040F Hot water bag

7. Physiological effects cold
application
• Peripheral Vasoconstriction
• Decreased capillary permeability
• Decreased oxygen consumption
• Decreased local metabolism
• Increased blood viscosity
• Decreased muscle tone
• Decreased blood flow
• Decreased lymph flow
• Decreased motility of leucocytes

8. Variables Affecting Physiological
Tolerance to Heat and Cold
• Body part. The back of the hand and foot are not very
temperature sensitive. In contrast, the inner aspect of the wrist
and forearm, the neck, and the perineal area are temperature
sensitive.
• Size of the exposed body part. The larger the area exposed to
heat and cold, the lower the tolerance.
• Individual tolerance. The very young and the very old generally
have the lowest tolerance. Individuals who have neurosensory
impairments may have a high tolerance, but the risk of injury is
greater.
• Length of exposure. People feel hot and cold applications most
while the temperature is changing. After a period of time,
tolerance increases.
• Intactness of skin. Injured skin areas are more sensitive to
temperature variations.

9. Local Effects of Cold
• Cold lowers the temperature of the skin and underlying
tissues and causes vasoconstriction.
• Vasoconstriction reduces blood flow to the affected area
and thus reduces the supply of oxygen and metabolites,
decreases the removal of wastes, and produces skin
pallor and coolness.
• Prolonged exposure to cold results in impaired
circulation, cell deprivation, and subsequent damage to
the tissues from lack of oxygen and nourishment.
• The signs of tissue damage due to cold are a bluish
purple, mottled appearance of the skin, numbness, and
sometimes blisters and pain.
• Cold is most often used for sports injuries (e.g., sprains,
strains, fractures) to limit post injury swelling and
bleeding.

10. • Systemic Effects of Cold
• Cold applications and vasoconstriction, a
client’s blood pressure can increase because
• blood is shunted from the cutaneous
circulation to the internal blood
• vessels. Shivering, a generalized effect of
prolonged cold, is a normal response as the
body attempts to warm itself.

11. Classifications of Cold Applications
Local General
Dry cold Moist cold Dry cold Moist cold
Ice bag
Ice collar
Ice pack
(poultice)
Ice cradle
Chemical cold
packs
Ice to suck
Cold
compress
Evaporating
lotion
Hypothermia
Hypothermia Cold sponging
Cold bath
Cold packs

12. Rebound Phenomenon: Cold
• Maximum vasoconstriction occurs when the
skin temperature reaches 150 or in about
30 minutes to one hour.
• Vasodilation begins as a protective device to
prevent the body tissue from freezing
• Recovery time of one hour is best before
reapplication.

13. Factors affecting heat and cold
tolerance
• Body part: Certain areas of the skin have a sensitivity to
temperature variations. The inner aspect of the wrist
and forearm, the neck, and the perineal area are
temperature-sensitive, while the back of the hand and
the foot are not as sensitive.
• Duration of application: Therapeutic benefits of heat and
cold applications are achieved with short periods of
exposure to temperature variations. Tolerance increases
as the length of exposure increases.
• Area of body exposed: The larger the area exposed to
heat and cold, the lower the tolerance to temperature
changes.

14. • Damage to body surface area: Injured skin
areas are more sensitive than intact areas to
temperature variations.
• Individual tolerance: Tolerance to temperature
variations is affected by age and physical
condition. The young and the aged are
especially susceptible to heat and cold.
• Age: Thinner skin layers in children and elderly
people increase the risk for burns from the
heat and cold applications.

15. Therapeutic uses of local cold
applications
• Indications
– Relieves pain
– Prevent gangrene
– Prevent edema & reduce inflammation
– Control hemorrhage
– Control the growth of bacteria
– Reduces the body temperature
– Anaesthetize an area

16. Contraindications of cold
applications
• State of shock & collapse
• Edema
• Diseases associated with impaired
circulation
• Muscle spasm
• Decreased sensation
• Shivering

17. Complications
• Pain
• Blisters and skin breakdown
• Maceration (with moist cold)
• Grey or bluish discoloration
• Thrombus formation
• Redness (secondary effect)
• Hypothermia

18. Hemodynamic Effects of cold
• Immediate vasoconstriction
– Less than 15 minutes
– Stimulates smooth muscles of vessels to contract
– Decreases release of histamine, prostaglandins (vasodilators)
– Increases blood viscosity (increases resistance to flow)
– Decreases blood flow to maintain core temperature
• After 15 minutes, vasodilatation occurs
– Mostly distal extremities
– Temperatures < 10 C (350 F) >15 minutes
– Cold induced vasodilatation (COVD
– Amount of vasodilatation usually small
– Skin redness NOT due to vasodilatation
– Due to increase in oxyhemoglobin concentration of blood
• Cold decreases oxyhemoglobin dissociation
• Makes less oxygen available to tissues
• Hunting Response
– Response to pain associated with extreme cold

19. Raynaud's Phenomenon
• A vascular reaction to cold application or stress
that results in a white, red, or blue discoloration
of the extremities. The fingers and toes are the
first to be affected
– Raynaud's phenomenon is a condition resulting from
poor circulation in the extremities (i.e., fingers and
toes). In a person with Raynaud's phenomenon, when
his or her skin is exposed to cold or the person
becomes emotionally upset, the blood vessels under
the skin tighten and the blood flow slows
– This happens because the blood vessels under the skin
tighten. When blood does not reach parts of the body,
these areas may turn blue and feel cold.

20. Neuromuscular Effects of Cold
• Muscle Activity
– Decreased muscle spasm by decreasing muscle
spindle activity.
– Intramuscular fibers (muscle spindle) runs
parallel to fibers of the muscle. Muscle
contraction causes spindle contraction so it
remains sensitive. The lower the temperature,
the lower the spindle activity.

21. • Decreased Nerve Conduction Velocity
• Proportional to degree and duration of temperature
change
– Application of cold > 5 minutes
– Reverses (normal) within 15 minutes
– After 20 minutes, may take 30 minutes or more to
recover.
• Decreased Nerve Conduction Velocity Decreased
NCV of sensory and motor nerves occurs
– Greatest effect in myelinated, small fibers pain
transmitters
– Least effect in unmyelinated, large fibers

22. • Increased Pain Threshold
– Counter-irritation via Gate Theory
• Secondary to decrease in muscle spasm
• Secondary to decrease in sensory NCV
– Secondary to post-injury edema reduction
(decreased blood flow)
• Reduces pressure on nerves due to edema

23. Metabolic Effects of Cold
• Decreases Metabolic Rate
• Decrease inflammatory response
• Delay in wound healing process

24. Physiological Effects of Cold
• Metabolic
– Decreased secondary cell deaths by hypoxia (swelling
prevents oxygen from reaching cells). The decrease in
metabolism allows them to live without as much oxygen.
– Normal body temperature is 37 ° C.
– Increase above 45° C (113° F) proteins denature
– Reduction of edema through decreased capillary hydrostatic
pressure and decreased permeability and osmotic pressure
– Increase blood viscosity (make it thicker so it won’t flood the
area as quickly)
– Decrease in chemical mediator effectiveness (they cause
vasodilatation)

25. • Inflammation Control
– Decreases chemical reactions secondary to acute
inflammatory response
– Decreased blood flow secondary to vasoconstriction,
increased viscosity
• Causes secondary decrease in bleeding, edema
• Increased function during this stage of healing
• Prophylactically after exercise to decrease DOMS
(Delayed Onset Muscle Soreness)
– Due to muscle connective tissue damage secondary to
exercise

26. • Edema Control
– Decreases intravascular fluid pressure via
decreasing blood flow, increased viscosity ◦
• Most effective if applied immediately, in conjunction
with elevation and compression
– Cryotherapy ineffective with edema secondary
to immobility and poor circulation.

27. R-I-C-E-S: Rest, Ice, Compression,
Elevation, Stabilization
• RICES serves to counteract the body’s initial
response to injury
• Rest: It limits scope of original injury by
preventing further trauma
• Ice: Ice can decrease cell’s metabolism,
reducing the amount of secondary hypoxic
injury by enabling tissues to live on limited
oxygen and secondarily reduce pain
– Crushed ice is the ideal form of cold application
during initial injury because it produces the most
rapid temp. decrease.

28. • Compression:- It decreases the pressure
gradient between blood vessels and tissue
and discourages further leakage from
capillaries. ◦
• Also Encourages Lymphatic drainage
• Compression Types
– Circumferential - provides even pressure
– Collateral - Pressure on 2 sides (aircast)
– Focal Compression - U-shaped horseshoe pads

29. • Elevation:- It decreases the hydrostatic
pressure within the capillary beds to
encourage absorption of edema by lymphatic
system
– This has the greatest effect at 90° perpendicular to
the ground at 45 ° the effect of gravity is 71%
comparatively
• Stabilization:- It limits muscle spasm & neural
inhibition related to guarding the injured area
– Early stabilization eases the pain-spasm-pain cycle
by letting the muscles relax

30. Pain Control
• 10-15 minute application can control pain for 1 or
more hours.
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 or mentation
• Very young or very old
– impaired temperature regulation
– ability to communicate

31. Adverse Effects
• Tissue Death
• Frost Bite
• Nerve damage
– Unwanted vasodilation due to prolonged
vasoconstriction, ischemia, thromboses in smaller
vessels.
• Freezing of tissues
– damage at 39 degrees F
• To avoid, duration limited to under 45 minutes and
tissue temperature above 39 degrees F
• When goal is vasoconstriction, treatment limited to
10-15 minutes

32. Application of Cold
• Assess patient and establish goals of
treatment
• Determine if cryotherapy most appropriate
treatment
• No Contraindications
• Select appropriate mode of application
based on body part and desired response

33. Dry Cold
• Explain procedure, reasons for treatment, and expected
sensations
• Fill two-thirds full with crushed ice so bag is easier to
mold over body part.
• Cover bag with towel or pillowcase and apply to affected
area for 30 minutes.
• Provides cold to localized area (e.g., muscle sprain,
hematoma) to Ice bag, ice collar
• Application of Cold
• Ice Bags
• Crushed ice best - conforms better
• Get all/most air out of bag.
• Colder than ice packs
– specific heat of ice higher than gels
• Either decrease time or provide slight insulation.

34. COLD PACKS
• Commercially prepared single-use ice packs
provide cold for designated period of time.
• When the pack is squeezed or kneaded, an
alcohol-based solution is released, creating the
cold temperature.
• Commercial
– Silica or mix of saline/gel
– Stored in freezer at 23º C
– Moldable to patient’s body
– Should be cooled at least 30 minutes between
treatments or 2 hrs. prior to initial use.

35. COLD PACKS

36. Cold Packs
• Ice Bags
• Reusable Cold Pack
• Instant Cold Back
• Treatment time for all are 15-30 minutes
– Because of lasting effects application should be
no less than 2 hours apart
– For controlled Cold Therapy Units - may be
applied continuously for 24 to 48 hours post
acute injury or surgery

37. • Indications
– Acute injury (may use with wet wrap)
– Acute or Chronic Pain
– Postsurgical Pain and Edema
– Shape of Body part
• Precautions
– Acromioclavicular joint (AC joint) and other areas may
not be suitable for wet wrap
– Tension of elastic wrap should be enough to provide
adequate compression without unwarranted pressure
– Ensure Circulation w/wrap
– Frostbite - chance for reoccurrence
– Over large or superficial nerves

38. Advantages and Disadvantages of
Ice Packs/Cold Packs
Advantages
• Advantages of Easy to use
• Inexpensive
• Short use of clinician’s
time
• Low skill level required
• Covers moderate to large
areas
• Can elevate limb
simultaneously
Disadvantages
• Must remove pack to
inspect skin
• Patient may not tolerate
weight
• Difficult to mold to
contoured areas
• Longer treatment time
(than ice cup)

39. 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.

40. ICE TOWEL
• Instant cooling towels work on the principle
of evaporative cooling. This is the reduction
of a surface temperature that occurs when
the evaporation of a liquid takes place. The
instant cooling towel absorbs water and
moisture and distributes it evenly
throughout the fabric. This regulates the
evaporation which keeps the towel cooler
for longer periods of time.

41. ICE TOWEL

42. Ice Massage or Ice Cup
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.
Ice Massage
• Appropriate for delivering cold treatment to small evenly
shaped areas.
• Most effective for muscle spasm, contusion and other minor
well-localized areas
Duration of treatment
• 5-15 minutes or until ice runs out
• if the purpose is analgesic, then stop when numb

43. Indications
• Subacute inflammation or injury
• Muscle strain ◦ Contusion
• Acute or chronic pain
Contraindications
• All other ice contraindications
• When pressure is not warranted
• Suspected Fracture
Precautions
• Injuries where pressure massage may be
contraindicated

44. Application of Ice Massage
• Use towels in surrounding
areas to catch drips.
• Use small, overlapping
circles
• Keep ice moving rapidly
• Continue for 5-10 minutes
or until analgesia achieved
• “Quick Icing” used as quick
strokes with ice cup to
facilitate motor response

45. ADVANTAGES OF ICE
MASSAGE
• Treatment area can be
observed during treatment
Excellent for small,
irregular areas
• Short-duration of
treatment
• Can elevate limb if desired
DISADVANTAGES OF ICE
MASSAGE
• Requires clinician
throughout treatment,
unless patient independent

46. Cold soaks
• Procedure similar to that for warm soaks.
• Desired temperature for a 20- minute soak
is 15°C (59°F).
• Take precautions (such as preventing drafts
and draping shoulders) to prevent client
from chilling.
• Intermittent Cold Compression and Cryocuff

47. Cold soaks

48. Cold Compresses
• Applied to either decrease or prevent bleeding and to reduce
inflammation.
• Procedure similar to that for warm compresses except cold
compresses applied for 20 minutes at a temperature of 15°C
(59°F).
• Technique may be clean or sterile.
• Observe for signs and symptoms of burning or numbness,
mottling of the skin, redness, extreme paleness, or a bluish skin
discoloration.
Controlled Cold Compression
• Intermittent Compression/ Cold Pump
– Usually used in post-op patients
– Allows for intermittent cold and compression proven more
effective than ice alone

49. Cold Compression Unit
• Cold water is
circulated in a sleeve
which Is put over the
limb and part of it is
inflamed at intervals.

50. Cryocuff
• A cryocuff is a portable
device, filled with water,
which is cooled in the
fridge and then wrapped
around the knee. The
combination of pressure
and cold helps to reduce
pain and swelling, which
will help to recover
more quickly.

51. COLD/ ICE SPRAYS
• An effective spray
bringing temporary pain
relief to Sports related
Muscular Pain including
Sprains or Strains, Back
Pain and Sports Injury.

52. 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.

53. Vapocoolant Sprays
• Ethyl chloride
• Fluorimethane sprays
• Work by rapid cooling
• Desired treatment of trigger points
• Applied in parallel strokes along skin of
muscle immediately prior to stretching

54. Cryokinetics
• Cryotherapy can be combined with rehabilitative exercise to
decrease pain during the exercise using a technique
called cryokinetics. Cryokinetics allows the patient to perform
exercises sooner and more effectively. part for a maximum of 20
minutes, or until the area is numbed. The patient then performs
exercises.
Purpose:
• To apply cooling agent to point of numbness shortly after injury
• to decrease sensation of pain, allow patient to exercise toward
regaining ROM. (Athletics)
• Cold for 20 minutes (numbness)
• Exercise for 3-5 minutes
• Re-cooling
• Repeat about 5 times

55. • Contraindications
– Any exercise or activity that causes pain
– Use of ice on a patient who is hypersensitive to cold
• Precautions
• Use pain as a guideline.
– Warn patient not to gut out pain.
• Don’t allow patient to limp.
• May be an increase in pain 4–8 hr after
treatment

56. Principles of Cryokinetics Exercise
• All exercise should be active.
– Performed by the patient
• Exercise must be graded
– Begin with range of motion exercises.
– Progress through increasing levels of difficulty.
– Full sport activity is final level.

57. • Non-weight-bearing
ROM
– Plantar flexion
– Dorsiflexion
– Inversion
– Eversion
– Circumduction
• Weight-bearing ROM
– Stand up.
– Shift weight from foot to
foot.
– Gradually increase weight
on injured limb.
Indications
• Sprains—dynamite
treatment
– Ankle (especially)
– Fingers
• Strength training

58. Cryostretch
• A technique used to reduce muscle spasm by
combining cold applications to produce
numbness with proprioceptive neuromuscular
facilitation. The body part is numbed using an
ice pack or vapocoolant spray and then muscle
elongated using proprioceptive neuromuscular
facilitation techniques. The ice application and
exercise are repeated, to stretch and fatigue the
involved muscle group.
• “Spray and Stretch” using vapocoolant
• Traditionally preformed with ethyl chloride
due to its ability to quickly evaporate and cool
superficial tissue

59. • This technique is used as a counterirritant
– Masks the symptoms to allow for a stretch
• Cooling prior to stretching
– Decreases spasm, secondary increase in ROM
– Spray n’ Stretch,
– Fluoro-methane Spray
• If patient condition not improving or
worsening within 2-3 treatments,
– Approach should be re-evaluated and changed

60. Cryostretch
• Precautions
– Can Cause frostbite
– Ethyl Chloride is extremely flammable
– Ethyl Chloride is a local anesthetics but if inhaled can
become general
– It’s use is based on tradition rather than fact
• Contraindications
– Allergy
– Open wounds
– Post/surgical
– Eyes
– All other cold & passive stretch contraindications
• Indications
– Trigger points
– Muscle spasms
– Decreased ROM

61. Cold whirlpools
• Duration of Treatment
– 15-20 minutes
– Temp 50° - 60 ° F
• Indications
– Decrased ROM
– Cryokinetics
– Subacute to chronic inflammation
– Peripheral nerve injuries (avoid extremes)

62. • Contraindications
– Acute conditions where water turbulence would
further irritate area
– Gravity
– Postural
– Skin Conditions
– All other ice contraindications

63. Guidelines in application
• Determine the client’s ability to tolerate the therapy.
• Identify conditions that might contraindicate treatment (e.g.,
bleeding, circulatory impairment).
• Explain the application to the client.
• Assess the skin area to which the heat or cold will be applied.
• Ask the client to report any discomfort.
• Return to the client 15 minutes after starting the heat or cold
therapy, and observe the local skin area for any untoward signs
(e.g., redness). Stop the application if any problems occur.
• Remove the equipment at the designated time, and dispose of it
appropriately.
• Examine the area to which the heat or cold was applied, and
record the client’s response.

64. Safety Measures
“DO’s”
• Do explain to the patient sensations to be felt
during the procedure
• Do instruct the patient to report changes in
sensation or discomfort immediately
• Do provide a timer, clock, or watch so that the
patient can help the nurse time the application
• Do keep the call light within the patients reach
• Do refer to the agency’s policy and procedure
manual for safe temperatures

65. Safety Measures
Do “NOTS”
• Do not allow the patient to adjust the
temperature
• Do not allow the patient to move an application
• Do not place the patient in a position that
prevents movement away from the
temperature source
• Do not leave patient who is unable to move or
paralyzed

66. References
• Taylor, C., Lynn, P., & Bartlett, J. L.
(2019). Fundamentals of nursing : the art
and science of person-centered nursing
care (9th ed.). Wolters Kluwer.
• Kozier, B. (2018). Fundamentals of Canadian
nursing : concepts, process, and practice.
Pearson
• Lehmann, J. F. (1990). Therapeutic heat and
cold. Williams & Wilkins.

67. THANK YOU