Thermal Agents: Cryotherapy

Basics of Heat
Heat: a term used to describe the energy that matter can store in the form of electronic, atomic, or molecular motion.
The great the molecular motion, the greater the heat production

Basics of Cold
Cold: in a physical sense is a negative condition, depending on the decrease in the amount of molecular vibration that constitutes heat. The less the molecular motion, the less heat production. Thus, a sensation of cold results.

Temperature:
Temperature is a measure of the average amount kinetic energy possessed by an individual molecule of a body (kinetic theory of heat).
Temperature is a measure of sensible heat of cold in a body. Temperature is expressed as Fahrenheit or Centigrade.

Classification of temperatures: for treatment purposes, are classified as follows:

Very Cold Cold Cool Neutral Warm Hot Very Hot
Hot

32 to 55 F 55 to 65 F 65 to 80 F 80 to 92 F 92 to 98 F 98 to 104 F 104

Transfer of energy: heat, or the loss of hear, occurs in any of the following ways:
Conduction: Contact Convection: movement Evaporation: through liquid-gas transfer Radiation: electromagnetic waves Conversion: transfer from one energy type to another

Factors in heat transfer Cont

Conductivity: the power of transmitting heat, electricity or sound. A tissues conductivity is usually dependent on the water content; the higher the water content the better the conductivity
Muscle - 72-75% water and conducts well Bone and skin are 5-16% water and poor conductors

Factors in heat transfer Cont

Resistance: the tissues opposition to the passage of energy
Expressed in Ohms.
Bone and fat have high resistance Muscle and Skin low

Cryotherapy
Used to describe the application of cold modalities that have a temperature range between 32 and 65 F

Cryotherapeutic Benefits
To obtain therapeutic benefits
skin temp. must be reduced to 57 F for optimal decrease in local blood flow skin temp must be reduce to 58F for analgesia Skin tempertaure must be reduced to 36F to produce intra-articular temp. changes in the knee
The temp of the skin over a joint decreased the temp in a joint proportionally 10 F skin 6.5 F joint

Also remember that temperature is relative!

Effects of Cold on Application Site

Vasoconstriction Decreased Rate of Cell metabolism resulting in a decreased need for oxygen Decreased production of cellular wastes Reduction of inflammation Decreased Pain Decreased Muscle Spasm

Systemic Effects of Cold Exposure

General vasoconstriction in response to cooling of the posterior hypothalamus (this happens with a .2F of circulating blood Heart rate is decreased Respiration Decreases Shivering and increased muscle tone
If core temperature continues to drop this is the bodys response to increase heat IN GENERSAL THIS DOES NOT OCCUR WITH ICE APPLICATION!

The Effects of Ice on Injury Response

Indications
Acute injury or Inflam Acute or chronic pain Small 1st degree burns Postsurgical pain and edema In conjunction with rehab ex. Neuralgia Acute or chronic muscle spasm Spastically accompanying CNS disorders

Contraindications
Cardiac or Resp. involvement Uncovered open wounds Circ. Insufficiency Cold Allergy Anesthetic Skin Advanced Diabetes Raynauds Phenomenon

Raynauds 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. This is a sympathetic nervous system reflex

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

Physiological Effects of Cold: Metabolic

Reduction of edema through decreased capillary hydrostatic pressure and decreased permeability and osmotic pressure Increase blood viscosity (make it thicker so it wont flood the area as quickly) Decrease in chemical mediator effectiveness (they cause vasodilatation)

Physiological Effects of Cold: Metabolic

Decreases below 15 C (58 F) a hunting response (Lewis 1932) incurs
Histamine like release yields an increase vasodilatation as a self defense response

Arterio-venal anastomoses (artery directly to veins) allow pooling of blood in feet, hands, ears, and lips. May be place of hunting response Dont go below 58 F and keep time shorter than 30 minutes to be on the safe side

Physiological Effects of Cold: Pain

Local decrease in free nerve ending sensitivity Increases the threshold for nerve firing Slows synaptic activity Allows disruption of pain-spasm-pain cycle via analgesia

Physiological effects of cold: Hemodynamic

Vasoconstriction from smooth muscle in arterioles reflex vasoconstriction from A-delta (spinal reflex to preserve body heat) Cold blood hits hypothalamus and may start shivering response if cold enough A small amount of vasoconstriction gives a 4 fold decrease in blood flow

Muscle Activity
Decreased muscle spasm by decreasing muscle spindle activity. Intramuscular fibers (muscle spindle) runs parallel to fibers of the muscle. Ia and II run to dorsal horn of spinal cord and respond to stretch. As the muscle contracts the spindle contracts so it remains sensitive. Cold directly decreases the activity in the Ia and II fibers. The lower the temperature, the lower the activity.

Effects of Immediate Treatment

RICE - Rest, Ice, Compression, Elevation
Serves to counteract the bodys initial response to injury Rest limits scope of original injury by preventing further trauma Ice - function is to decrease cells metabolism, decrease the need or oxygen and reduce 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.

Effects of Ice on Immediate Tx

Compression 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

Effects of Ice on Immediate Tx

Elevation
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

Cryokinetics
The use of cold in conjunction with movement
Used to decrease pain and allow for free motion through the normal ROM Results in more pronounced macrophage reaction, quicker hematoma resolution, increased vascular growth, faster regeneration of muscle and scar tissue Initiated when the underlying soft tissue and bone are intact and the pain is limiting the amount of function

Penetration depends on many factors:

Cold has a longer wavelength than heat Local temperature gradient Treatment surface area covered thickness and characteristics of tissue treated (fat is an insulator, tissues with high water content have better heat transfer)

Clinical Application
Cold Pack Ice Massage Ice Immersion Cryostretch Whirlpools Slides in Packet for specific review of each Clinical Application

Cold Packs
Ice Bags, Reusable Cold Pack Instant Cold Back Tx 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

Cold Packs
Indications
Acute injury (may use with wet wrap) Acute or Chronic Pain Postsurgical Pain and Edema Shape of Body part

Precautions
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 - if had before chance for reoccurrence over large or superficial nerves

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

Ice Massage
Indications
Subacute inflam or inj Muscle strain Contusion Acute or chronic pain

Precautions
Injuries where pressure massage may be contraindicated

Contraindications
All other ice contraind. When pressure is not warranted Suspected Fx

Ice Immersion
Temp. 50 - 60 F Time 10-20 min. Indications
Acute Injury or Inflam. Acute or Chronic Pain Post surgical pain

Contraindications
Same as general Contraindications Acute injury where gravity is contraindicated

Cryostretch
Spray and Stretch vapocoolant Traditionally preformed with ethyl chloride due to its ability to quickly evaporate and cool superficial tissue This technique is limited to a counterirritant
simply masks the symptoms to allow for a stretch

Cryostretch
Precautions
Can cause frostbite Ethyl Chloride is extremely flammable Ethyl Chloride is a local anesthetic but if inhaled can become general Its use is based on tradition rather than fact

Contraindications
Allergy Open wounds Post/surgical Eyes All other cold contraind & contraind to passive stretch

Indications
Trigger points Muscle spasms Decreased ROM

Cold Whirlpools
Duration of Tx
15-20 minutes Temp 50 - 60 F

Contraindications
Acute conditions where water turbulence would further irritate area Gravity Postsutural Skin Conditions All other contraindications

Indications
Decreased ROM Cryokinetics Subacute to chronic inflammation Peripheral nerve injuries (avoid extremes)