Cryotherapy Guidelines

Developed by:
A. Hoens, Physical Therapy Knowledge Broker (UBC Department of Physical Therapy, Physiotherapy Association of BC, Vancouver Coastal Health Research Institute, Providence Health Care Research Institute)
M. Paul, Clinical Nurse Educator (OASIS Program, Vancouver Coastal Health)

When, Why, and How

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Key Considerations

Inflammation, edema and swelling

These terms are NOT synonymous

• Each symptom is associated with a different phase in the ‘continuum of resolving inflammation’
• The specific clinical problem and the desired mechanism of action should guide the selection of the intervention
  

Is there an optimal ‘dosage of cryotherapy?’

There is no optimal dosage that is ideal for all body locations. Consider the nature of the tissue when icing:

• The duration of icing for a small area with minimal fat and muscle, such as a finger, would be significantly less (~3‐5 minutes) than that for a larger area and deeper tissue such as at the hip (~20 minutes)
• Intermittent icing (e.g., 10 minutes on: 10 minutes off) may be more effective for management of acute inflammation than icing for 20 consecutive minutes

Type/duration of cooling dependent upon the goal

Cooling to reduce pain will likely require less intense (ice pack) and shorter durations (5 minutes)

• Cooling to reduce metabolism of uninjured cells will likely require more intense cooling (ice bath or ice chips in a wet towel) for longer durations (10‐15 minutes)
• The hierarchy of the efficiency of cooling from most to least: ice‐water immersion, crushed ice, frozen peas and gel pack
  

Possible Risks/Undesirable Effects

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 toweling)
• 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 fibers 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

Be aware of conditions in which icing is contraindicated

• E.g. CRPS, hemoglobinuria, cryoglobinemia, Raynaud’s disease and cold uticaria

References

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Bleakley CM et al (2010). Is it possible to achieve optimal levels of tissue cooling in cryotherapy? Physical Therapy Reviews. 15(4): 344‐350.
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