a concise view of cryotherapy

1. CRYOTHERAPY

2. Content
• Introduction
• Factors affecting Cryotherapy
• Physiological changes
• Uses of Cryotherapy
• Methods of Cryotherapy
• Cryotherapy in rehabilitation
• Recent articles

3. Cryotherapy
• The term Cryotherapy comes from Greek
Cryo-cold, Therapy- cure
• Cryotherapy has been used as early as 17th
century.
• Cryotherapy refers to use of local or general
body cooling for therapeutic purposes.

4. Cryotherapy
Factors which affect the cooling of the tissue
1) Cooling source
2) Any barriers to cooling eg: dry towel,
presence of oil etc
3) Thermal conductivity of body surface
4) Rate of blood flow
5) Duration of exposure

5. Physiological changes
Physiological
changes
Local effects
On Cutaneous
blood vessels
On deeper
blood vessels
On tissue
metabolism
On peripheral
nervous sys
On motor
system
General
effects

6. Local effects
On cutaneous blood vessels
• Causes immediate vasoconstriction because of
ANS reflex triggered by thermal receptors
• There will be decreased blood flow because of
viscosity is increased

8. Local effects
• LEWIS HUNTING reaction - Their will be
alternation of constriction and vasodilatation
following application of ice
• Approximately five to ten minutes after the
start of cold exposure, the blood vessels in the
extremities will suddenly vasodilate.
• This is probably caused by a sudden decrease
in the release of neurotransmitters

9. LEWIS HUNTING REACTION

10. Local effects
On deeper tissue blood flow:
• Deeper tissue tends to cool and rewarm slowly
than the skin
• At 2 to 3 cm depth temp drops after 20 mins
application of cold pack -Enwemeka et al 2002
• At 8°C diameter of blood vessel decreases by 43%
over 30 mins this causes reduction in blood flow
by 80%
• Decrease in blood flow doesn't cause tissue
damage because cellular metabolism is also
decreased

11. Local effects
On tissue metabolism
• The principal effect of cooling living tissue will be
to reduce its metabolic rate in accordance to
Van’t Hoff Law.
• It states that the rate of any chemical action that
can be affected is increased/decreased by a
temperature rise/fall.
• Metabolism being a series of chemical reactions
will decrease with a fall of temperature.

12. Local effects
On PNS:
• When we immerse the hand in water immediate
sensation will be cold , numbness and followed
by deep aching pain
• Cold - A δ fibers.
• Deep aching pain - activation of nocioceptors
which is carried by C fibers
• Cryotherapy decreases synaptic transmission.
• This effect is helpful in treating pain and
hypertonicity.

14. Local effects
On motor system
• Locally applied ice(ice towel) has been shown to
↑ isometric strength and endurance of
quadriceps
• But their effect is limited to low amount and
shorter duration of cooling
• But there are evidences that the strength
increases over the original value about an hour
after cooling has ceased.
• Cooling reduces the tremor by slows nerve
conduction

15. General effects of cooling
• When cooling applied to the skin stimulates
cold receptors
• Both pain and temp fibers synapses in post
horn of spinal cord reaches thalamus , sensory
cortex and to hypothalamus
• Via vasomotor center causes vasoconstriction
• Further decrease in temp leads to shivering.
This increases the rate of metabolism for heat
production

16. General effects of cooling
Cooling stimulates cold receptors
Reaches post horn of spinal cord
Through Spinothalamic tract
Fibers reaches Thalamus, Sensory
cortex and Hypothalamus
VC through vasomotor responses

17. Cryotherapy
Uses of cooling :
1) Recent injuries
2) Pain
3) Postoperative
4) Muscle spasm
5) Spasticity
6) Muscle strengthening
7) Chronic inflammatory conditions
8) Chronic oedema and joint effusion

18. Recent injuries
• Cooling causes vasoconstriction and makes
blood more viscid
• Will diminish edema and alleviates pain.

19. Pain
Mechanism:
• Reduction in extent of local inflammation and
by blocking effect of cold on transmission of
fast pain.

20. Postoperative uses
• Cryotherapy is used in post arthroscopic
reconstructions of the ACL
• Post operative Carpal tunnel release, Hip
arthroplasties, Knee arthroplasties
↓pain
Faster rate of
regaining movement
↑ rate of discharge

21. Spasticity and 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

22. Muscle strengthening
• Shorter application increases Muscle strength
by facilitator effect on α motor neuron
• Sympathetic stimulation has also been
suggested has also been suggested
• Where prolonged intensive cooling leading to
weakness.

23. Methods of applying Cold therapy
1) Ice pack
2) Commercial Cold Packs
3) Cryotherapy flow unit
4) Local immersion
5) Ice towels
6) Ice Massage
7) Ice Wrap
8) Evaporating Sprays
9) Whole body Cryotherapy

24. Ice Pack
• Ice pack is the most widely used
treatment
• Flaked ice is folded into towel or
bag and applied directly to skin
• Skin under ice bag reaches upto
12.5° C
• When dry towel applied b/w it
reaches 23.5 ͦC
• Ice pack should be removed after 1
min to inspect the skin

25. Commercial ice pack
• 2 forms
1) Reusable – Gel pack
2) Single use – Endothermic pack
 Gel pack: reusable pack filled with gel
prevents freeze so it remains flexible
• Due to rewarming gel pack provide
cooling less than 20 mins
• Usually applied to ankle or knees or
for small areas
• It should be applied over towel to
prevent ice burn

26. Endothermic Ice pack
Endothermic or chemical pack:
single use cold pack
• Instant cold pack is consists of
two bags, one containing water
and other containing ammonium
nitrate, calcium ammonium
nitrate or urea
• This reaction absorbs heat from
the surroundings, quickly
lowering the pack's temperature.

27. Cryotherapy Flow unit
• It has water reservoir to which water is
added.
• This is connected to bag like unit via
insulated tube.
• The water is kept at thermostatically
preset temperature.
• The water is either pumped
continuously or intermittently.
• Commonly used in post operative
cases.
• Incidence of frost bite is extremely low
but risk of skin damage is high .

28. Local immersion
• This is the simplest method of all
• The part to be cooled is placed in the
container of iced water.
• Temp is controlled amount of ice used
• Can only be used to extremities
• When compared with ice pack rewarming
is slow in Local immersion .
• The extent of intramuscular cooling in a
cold whirlpool is slightly less at 20
mins(decrease of 5.1 ͦC) than if a ice pack
is used (7.1 ͦC decrease)

29. Ice towel
• The towel is placed in mixture of
flaked ice and water and then wrung
out
• Stays 20 Degrees C cooler than
ambient temperature
• Large rectangular size, ideal for
necks, legs and head
• keep cool during and after exercise.
• Advantage of this technique is allows
movement while cold therapy is
applied.

30. Ice massage
• A solid piece of ice cube wrapped in
paper or like an lollipop on a wooden
stick used to massage a small area
• The rate of local intramuscular
cooling produced using ice massage is
greater than if an ice pack is used
• Ice block should be moved over a
small areas in circular motion for 5 -
10 mins

31. Evaporating spray
• It causes very rapid cooling but
doesn’t last longer
• Modern spray contains
fluorimethane
• Series of short strokes of about 5
secs each
• Held about 45 cm from the skin
surface
• Frost bite is likely

32. Ice wrap
• A more recent method of cooling the skin
• Procedure: a crepe bandage is soaked in a
solution and then wrapped over the skin
• Level of cooling is less but effective longer
duration

33. Cryotherapy unit
• A compact unit providing cold air for treatment of musculoskeletal
system
 Procedure:
• Once the device is switched on Pre-cooling phase is initiated
• During this phase compressor and condenser fan work together to
reduce the temp
• Display will show pre-cooling mode to therapy mode
• After Pre-cooling phase wait for 5mins
• Then we can start the operational mode
• Fan speed and the treatment time can be adjusted directly
• Treatment ends automatically after the program completion
 Airflow rate: adjustable up to 9 level
 Treatment time : adjustable up to 100mins

34. Cryotherapy unit

35. Cryotherapy unit
Storage :
• Temperature - 10°C to – 70°C
• Pressure: 600 – 1200 hPa
Air temp at nozzle avg: -25°C
• Max :-35°C
• Min:-18°C

36. Cryotherapy unit

37. Whole body cryotherapy
• The Cryochamber is a multi-person walk-in device
which exposes the patient's entire body to hypercooled
room-air.
• Reach temperatures of about -110°C
• Individual will be place in the chamber for 1- 2 mins
twice daily
• Air is cooled by liquid nitrogen which is devoid of
moisture
• Only skin, muscle and subcutaneous tissue is cooled.
Organs are spared
• WBC is an established, effective treatment for
inflammatory disorders and injuries.

38. Whole body Cryotherapy
Treatment procedure:
• Patient first goes through 1st chamber -10°C
for 10 secs
• 2nd chamber -60°C for 10 secs
• 3rd chamber -110°C
• Patient will be monitored by CCTV

39. Whole body cryotherapy
 Uses:
• Reduces inflammation
• Lessens muscle soreness and tension
• Relieves pain from injuries or joint disorders
• Boosts metabolism and contributes to weight
loss
• Increases collagen production and signs of aging
• Improves mood via rise in endorphins
• Has an anti-oxide effect, which can slow aging
and help prevent osteoporosis
• Supports the treatment of multiple sclerosis
• Helps in insomnia, migraines, gout and asthma

40. Rehabilitation
Cryokinetics
Cryostretch

41. Cryokinetics
Introduction:
• Cryokinetics is a rehabilitation technique
involving ice application followed by
progressive active exercise
• Shown to be very successful in treating
ligament injuries

42. Cryokinetics
Effects:
• Cold decreases pain
• Exercise increases blood flow
• Exercise re-establishes neuromuscular
function

43. Cryokinetics
Advantages:
• Cryokinetics retards muscle atropy and neural
inhibition
• Reduces swelling rapidly
• Exercise increases the blood flow to the affected
part and promotes healing
• It re-establishes the neuromuscular function early
Disadvantage:
• Will be very painful during initial treatment

44. Cryokinetics
Indications:
• Ankle sprains
• Finger sprains
• Shoulder sprains
• Other joint sprains
Contraindications
• When Cryokinetics exercise causes pain
Precautions:
• Use pain as a guideline.
• Don’t allow patient to limp.

45. Cryokinetics
Application procedure:
a) Numb the body part using ice
immersion, ice massage or cold
pack for 20 mins
b) Exercise the affected part
Exercise should be
i. Active
ii. Progressive
iii. Pain free
c) Begin with active ROM to full
sport activity

46. Cryokinetics
 Exercise progression for ankle sprain
• Non weight bearing ROM
• Weight bearing
• Weight bearing ROM
• Walking
• Jogging
• Hopping and jumping
• Sprints
• Hopping and sprinting without ice
application
 Exercise–ice–exercise–ice
• Five exercise bouts per treatment

47. Cryokinetics

48. Cryostrech
• Cryostretch is a technique combining
Cryotherapy with stretching
• It involves 3 phases
a) Cold application
b) Static stretching
c) Relax technique

49. Cryostretch
• First cold application for 20 mins
• Following this two sets of 65 secs of stretch
should be applied with 20 sec rest in between
• There should not be any pain throughout the
procedure

50. Cryostretch
Effects:
a) Ice reduces muscle spasm allows muscle to
relax
b) Static stretches overcomes the stretch reflex to
reduce muscle spasm
c) Muscle relaxation will be more following the
stretch
 Disadvantage:
• Applying ice will be painful for some individual

51. Cryostretch
Indication:
• Grade 1 muscle strain
• Low grade muscle spasm

52. Dangers and CI
Excessive local cold on normal tissue:
a) Ice burn: Erythema and tenderness
of skin subsides in a day or two
b) A more severe form of ice burn with
fatty necrosis and more tenderness
last up to 3 weeks
c) Peripheral nerve damage
d) Frost bite
e) Immersion foot

53. Dangers and CI
Certain pathological condition:
a) Reduced peripheral vascular supply
b) Cold sensitivity
c) Cryoglobinemia
d) Cold utricaria
e) Cardiac disease
f) Arterial blood pressure

54. Recent articles
DOES WHOLE-BODY CRYOTHERAPY AFFECT THE
RECOVERY PROCESS AFTER HAMSTRING
DAMAGING EXERCISE: A CROSSOVER STUDY
BJSM -2014
• Hypothesized that WBC would have beneficial
effects on muscle recovery after such an exercise
bout.
• Conclusions The results of the present study do
not provide conclusive support for the use of
WBC as a technique to enhance functional
recovery after EIMD.

55. Recent articles
CRYOTHERAPY FOR ACUTE ANKLE SPRAINS: A
RANDOMISED CONTROLLED STUDY OF TWO
DIFFERENT ICING PROTOCOLS
BJSM 2008
• Compared standard cryotherapy with
Intermittent therapy
• The application of an intermittent cryotherapy
protocol after mild or moderate ankle sprain
significantly reduced the level of subjective pain
on activity, one week after the injury

56. Recent articles
Should Athletes Return to Sport After Applying
Ice?
A Systematic Review of the Effect of Local Cooling
on Functional Performance Chris M. Bleakley,1
Joseph T. Costello2 and Philip D. Glasgow
SMJ- 2012
• The current evidence base suggests that the
performance of athletes will probably be
adversely affected when ice is applied more than
20 mins