Cryotherapy

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Definition/Description

Cryotherapy, also known as ice application, is the simplest and oldest way to treat injuries. Its worldwide use spread because of its effectiveness, convenience, low cost and ease of transportation. Ice is believed to control pain by instigating local anaesthesia. It also decreases oedema, nerve conduction velocities, cellular metabolism and local blood flow. The effect of the cryotherapy depends on the method, the duration, temperature of the ice and the depth of the subcutaneous fat.

Application Methods

Application of cold pack

Ice Packs: It is most common method of cryotherapy. There are different types of ice used in ice packs. The most common types are ice packs made with cubed, crushed and wetted ice. It was discovered that wetted ice is better to lower surface temperature during treatment and maintaining the lower temperature during recovery. It is also more effective in lowering the intramuscular temperature during treatment.

ColPac

Commercial Cold Packs: Commercial cold packs, such as ColPac and Elasto-Gel, are an efficient and commonly used method of cryotherapy. Usually filled with a petroleum distillate gel material, these cold packs are quicker to apply and reach lower temperatures than traditional ice packs.

Vapocoolant Spray: Utilized as a superficial, cooling agent for reduction of muscle guarding and release of myofascial trigger points. (TEXTBOOK)

Immersion: Simple immersion, such as an ice bath, can be utilized for full concealment of a distal extremity (e.g., foot, ankle, hand, or wrist). Cold whirlpool is a form of immersion that transfers heat via convection

Application of ice massage

Ice Massage: Ice massage involves applying ice directly to the skin with slow strokes in circular motion for 5-10 mins. To achieve desired cooling effect, move the ice about 5-7cm/second. (TEXTBOOK)

Whole Body Cryotherapy: More recently whole-body cryotherapy has become popular for athletes, to help aid recovery, as well as in persistent pain patients such as rheumatological conditions. More research is needed to understand the effect on the body and its relation to pain.

Indications

Cryotherapy can be utilized as an adjunct to treatment for the following conditions: (Therapeutic Modalities TEXTBOOK)

• Acute soft tissue injuries (e.g., ankle sprain, muscular strain, ligament sprain)
• Myofascial trigger points
• Muscle spasm
• Muscle guarding
• Tendinitis
• Tenosynovitis
• Acute swelling
• Bursitis
• Post orthopaedic surgery (e.g., TKR, ACL reconstruction, arthroscopic shoulder surgery.)
• Reducing temperature
• DOMS

Contraindications

Be aware of conditions in which cryotherapy is contraindicated:

• CRPS
• Haemoglobinuria
• Cryoglobulinemia
• Peripheral vascular disease
• Impaired circulation
• Raynaud’s disease
• Urticaria
• Hypersensitivity to cold
• Skin anaesthesia
• Over a regenerating peripheral nerve
• Open wounds

Precautions

When applying cryotherapy, be cognizant of the following:

• Over a superficial nerve
• Hypertension
• Impaired cognition
• Patients who are very young or very old

Expected Sensations to Cryotherapy

Prior to the application of cryotherapy, it is important to understand the expected sensations that one might expect. While the sensations listed may be uncomfortable, they are both normal and necessary to achieve the desired effects from cryotherapy. Throughout the duration of treatment, the expected sensations begin with a cold feeling and should reach numbness by the end.

Physiological Effects of Cryotherapy (Therapeutic Modalities TEXTBOOK)

• Decreased local temperature
• Decreased metabolism
• Vasoconstriction of arterioles and capillaries, initially
• Decreased blood flow, initially
• Decreased nerve conduction velocity
• Decreased delivery of leukocytes and phagocytes
• Decreased lymphatic and venous drainage
• Decreased muscle excitability
• Decreased muscle spindle depolarization
• Decreased formation and accumulation of edema
• Extreme anesthetic effects

Lewis Hunting Reaction

The Lewis hunting reaction is a process of alternating vasoconstriction and vasodilation in extremities exposed to cold. The term Lewis reaction is used too, named after Thomas Lewis, who first described the effect in 1930. Vasoconstriction occurs first to reduce heat loss, but also results in strong cooling of the extremities. 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 from the sympathetic nerves to the muscular coat of the arteriovenous anastomoses due to local cold. This cold-induced vasodilation increases blood flow and subsequently the temperature of the fingers. A new phase of vasoconstriction follows the vasodilation, after which the process repeats itself.

Vasodilation can be cold induced after initial period of vasoconstriction when cold is maintained for longer than approximately 15 min or when temperature is reduced below 10C.

Pros

• Pain relief
• Swelling reduction
• Decreased surface temperature
• Effective on a wide range of soft tissue injuries

Cons

• Little evidence regarding duration and frequency of treatment to be effective
• Compression has been shown to be more effective post operatively
• In rare cases bradycardia and frostbite symptoms have been observed.
• Some more advanced cryotherapy devices can reduce range of movement following TKR due to immobilisation of the joint.

Possible Risks/Undesirable Effects

• Inhibit Muscle Function
• Ice Burn
• Cryotherapy-induced nerve injuries
• Generalized cooling and decrease in core temperature
• Reduced range of motion

Inhibit Muscle Function

• Cooling can temporarily Inhibit muscle function with potential for increased risk of injury/re‐injury
• Be cautious when having patients weight bear/undertake complex exercise after icing a lower extremity

Ice Burn

Elderly patients with impaired sensation and/or circulation will be more vulnerable to an ice‐burn, therefore consider using less intense icing techniques (e.g., moderately cold ice pack wrapped in an insulating layer(s) of towel/cloth)

• Younger patients with intact sensation and circulation may benefit most from direct immersion of the limb in cold water then progressively adding ice cubes
• Cold gel packs stored in a freezer have a surface temperature below 0°C (32°F) and thus an insulating layer should be used between the cold pack and the patient’s skin

Cryotherapy‐Induced Nerve Injuries

• Most common when cold is applied in combination with compression
• Check capillary refill during application of ice combined with compression therapy to ensure adequate blood flow

Generalized Cooling and Decrease in Core Temperature

• Shivering and piloerection are signs of decrease in core temperature which may compromise patient safety (especially in the elderly and those with fever)
• The application of therapeutic cryotherapy should produce only local effects

Reduced ROM

Ice may contribute to shortening of collagen fibres in connective tissue

• After gaining ROM by warming, stretching and then strengthening in the newest part of the ROM, it is likely counterproductive to cool the tissue in a shortened position
• If one wishes to cool the tissue post stretch and exercise, it is best to do so with the tissue in a lengthened position
• In patients with significantly restricted ROM due to scar tissue, it may be preferable not to use ice.