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Cold applications

This document discusses the use of cold applications in healthcare. It defines dry and moist cold therapies and their indications, which include reducing muscle spasm, inflammation, pain, traumatic injury, and more. The document outlines appropriate temperature ranges for different heat and cold applications and reviews the physiological effects of cold on the body, including vasoconstriction, decreased metabolism and inflammation. Contraindications and potential complications of cold therapy are also summarized.

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Cold Applications Dr. Binu Babu Ph.D, M.Sc. (N), MBA Mrs. Jincy Ealias M.Sc. (N)
• 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
• 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.
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.
• 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.
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
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
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.
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.
• 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.
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
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.
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.
• 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.
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
Contraindications of cold applications • State of shock & collapse • Edema • Diseases associated with impaired circulation • Muscle spasm • Decreased sensation • Shivering
Complications • Pain • Blisters and skin breakdown • Maceration (with moist cold) • Grey or bluish discoloration • Thrombus formation • Redness (secondary effect) • Hypothermia
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
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.
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.
• 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
• 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
Metabolic Effects of Cold • Decreases Metabolic Rate • Decrease inflammatory response • Delay in wound healing process
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)
• 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
• 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.
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.
• 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
• 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
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
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
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
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.
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.
COLD PACKS
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
• 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
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)
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.
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.
ICE TOWEL
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
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
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
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
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
Cold soaks
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
Cold Compression Unit • Cold water is circulated in a sleeve which Is put over the limb and part of it is inflamed at intervals.
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.
COLD/ ICE SPRAYS • An effective spray bringing temporary pain relief to Sports related Muscular Pain including Sprains or Strains, Back Pain and Sports Injury.
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.
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
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
• 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
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.
• 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
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
• 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
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
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)
• Contraindications – Acute conditions where water turbulence would further irritate area – Gravity – Postural – Skin Conditions – All other ice contraindications
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.
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
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
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.
THANK YOU

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Cold applications

  • 1.
    Cold Applications Dr. BinuBabu Ph.D, M.Sc. (N), MBA Mrs. Jincy Ealias M.Sc. (N)
  • 2.
    • Application ofheat 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 coldis 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 IndicationEffect 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 applicationis 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 heatand 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 Toleranceto 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 ofCold • 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 Effectsof 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 ColdApplications 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 heatand 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 tobody 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 oflocal 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 • Blistersand skin breakdown • Maceration (with moist cold) • Grey or bluish discoloration • Thrombus formation • Redness (secondary effect) • Hypothermia
  • 18.
    Hemodynamic Effects ofcold • 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 • Avascular 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 ofCold • 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 NerveConduction 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 PainThreshold – 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 ofCold • Decreases Metabolic Rate • Decrease inflammatory response • Delay in wound healing process
  • 24.
    Physiological Effects ofCold • 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:- Itdecreases 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:- Itdecreases 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 • 10-15minute 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 • TissueDeath • 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 • Explainprocedure, 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 • Commerciallyprepared 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.
  • 36.
    Cold Packs • IceBags • 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 – Acuteinjury (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 Disadvantagesof 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 • Wettowel 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 • Instantcooling 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.
  • 42.
    Ice Massage orIce 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 inflammationor 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 IceMassage • 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 • Proceduresimilar 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.
  • 48.
    Cold Compresses • Appliedto 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 cryocuffis 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 • Ethylchloride • 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 canbe 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 – Anyexercise 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 CryokineticsExercise • 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 – Plantarflexion – 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 techniqueused 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 techniqueis 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 – CanCause 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 • Durationof Treatment – 15-20 minutes – Temp 50° - 60 ° F • Indications – Decrased ROM – Cryokinetics – Subacute to chronic inflammation – Peripheral nerve injuries (avoid extremes)
  • 62.
    • Contraindications – Acuteconditions 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” • Doexplain 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.