Clinical applications of

Cryotherapy
Together with thermotherapy one of the most basic
and most common sources of physical therapy
It is safe, simple, inexpensive and its convenience of
use provide us with the necessary tools for primary
care of injuries

Mechanism of Heat transfer

All modalities that radiate energy with wavelengths
and frequencies that fall in the infrared region of the
electromagnetic spectrum are referred to as infrared
modalities
Ice packs, cold baths and other cold applications are
examples of such cold modalities used in PRM
Heat transfer occurs from our body to the cooler
object.. This net transfer of energy goes from our body
object
to the object
object,, and the body feels cooler.....conduction
cooler.....conduction
Therefore although cold exists, in reality it is a form
of lack of heat

Effects of cold on the circulation

Absorption of cold energy cutaneously over a long
enough period of time decreases the temperature of
the circulating blood and its flow in an area of
treatment
So, if the primary goal of a treament is to reduce
tissue temperature and blood flow, such a response
can only be done through the superficial application
of ice or cold
The main aim of such applications is to reduce tissue
damage and provide analgesia

Physiologic effects of tissue cooling

Cell permeability is decreased with a reflex activation
of the sympathetic adrenergic neurons.....constriction
neurons.....constriction
of the cutaneous vessels (local vasoconstriction of
smooth muscle by the CNS to conserve heat)
Reduces fluid filtration which decreases the potential
for oedema possibly due to decreased hydrostatic
pressure
The slower cellular metabolism results in less
inflammatory mediators, leukocytes and phagocytes,
and also contributes to less oedema

Effects of cold on muscle spasm

There seems to be a general understanding that the
mechanisms reducing muscle spasm lie at the level of
the muscle spindle.
spindle.
With cold the spindle afferent activity decreases and
persists as temperature is lowered (cold is usually
more effective in reducing muscle spasm)

The use of cold therapy on spasm

Ice or icing is used in two ways:
ways: short acting or
prolonged.
Brief use of ice can be used to facilitate a response
from muscle. In such instances an ice cube is swept
briskly over the chosen muscle belly.
belly.
Cold therapy is considered a therapeutic resource for
temporarily reducing spasticity symptoms. It consists
of lowering the stretch sensitivity of neuromuscular
spindles by reducing fibre
fibre activity in the gamma
system (decreasing nerve conduction velocity)
Martins et al. (2012).

The use of cold therapy on spasm(2)

Prolonged icing is mostly used in patients with
intractable muscle hyperactivity such as in some
individuals with MS.
This prolonged used of ice reduces afferent and
efferent neurotransmission (Jackson, 2007). To
reduce spasticity, the muscle spindle itself must be
cooled;; this
cooled
this explains the prolonged application of ice
given the depth and layers of tissue the cold therapy
must go through. 11-2hrs of reduction of spasticity can
be achieved allowing stretching or active exercises
with greater effect.

Physiologic effects of tissue cooling on large

body surface

When a large surface of the body is cooled, shivering

occurs as the result of a central reflex in the
hypothalamus
This raises the the core temperature as a result of heat
production
This might result in arterial vasoconstriction in other
remote parts of the body

Physiologic effects of tissue cooling:

Decrease in blood flow (through vasoconstriction)
and tissue metabolism
Bleeding and effects of acute inflammation such as
pain and oedema are significantly reduced
The nerve conduction velocity is decreased also
contributing to raising the pain threshold
Decrease in muscle spasm

Studies have also shown that using cold for too long
may be detrimental to healing as it disrupts the
healing sequence

Benefits of cryotherapy
Initial treatment in most acute musculoskeletal
conditions: most effective in the acute stages of healing
eg immediately following injury when loss of tissue
temperature is the aim of treatment
Decreases haemorrhage and oedema through
vasoconstriction
Reduces pain by slowing nerve conduction and
decreasing the excitability of the peripheral nerve fibres
and also possibly through a central effect (gate control
theory of pain modulation)
Help reduce severity of delayeddelayed-onset muscle soreness
& effective in managing myofascial pain

Benefits of cryotherapy(2)
Reduces reflex muscle spasm and spastic condition
that accompany it owing to local muscle irritability in
acute trauma. This is brought about by a decrease in
muscle spasm owing to a decrease in metabolites and
a decrease in accumulation of waste products
Can also enhance voluntary control in spastic
conditions
Decrease in muscular motor unit excitability
More effective when applied with compression to
reduce metabolism in the affected area
Cold is also used in combination with heat or other
methods in later stages of treatment

Indications and Contraindications

1.

Indications:
Acute and subacute inflammation
Acute or chronic pain
Acute swelling
Myofascial trigger points
Muscle guarding and spasm (decreased muscle
spindle activity)
Contusions, strains and sprains
Bursitis, tenosynovitis and delayed onset muscle
soreness

2. Contraindications:
Impaired circulation
Peripheral vascular disease
Hypersensitivity to cold (hives, joint pains, nausea)
Skin anaesthesia
Open wounds and skin disease
Infection

Cryotherapy treatment time

Depends on subcutaneous tissue thickness
Thin persons require shorter icing periods with better
response (Grant, McMaster et al)
Because of the low thermal conductivity of the fat
tissue, short cold applications are ineffective in cooling
deep tissues
Recommended treatment times range from 55-45 mins
for adequate effect up to around 48 hrs after trauma
Muscle tissue blood flow is reduced after around 20
mins (positron emission tomography (PET) which
quantifies local blood flow in response to cold). This
occurs in the most superficial layer suggesting that
therapeutic effects of ice decrease with tissue depth

Cryotherapy treatment time(2)

To produce similar intramuscular temperature
changes, Rx should be adjusted using skinskin-fold
thickness
Treatment time

Skin-fold thickness

25 min

20 mm

40 min

20-30 mm

60 min

30-40 mm

It is believed that cold therapy is more effective in

reaching deeper layers than most forms of heat
Effects of Rx depends on the type of cold application,
duration, thickness of adipose tissue and body region

Cryotherapy reaction & techniques

1.
2.
3.
4.

Cryotherapy produces a 44-stage reaction:

Sensation of cold
Stinging
Burning or aching feeling
Numbness
Erythema occurs when the temperature decreases to
below 5 degrees as vasodilatation occurs
occursHunting
reaction
Each stage is related to decreased blood flow and
nerve conduction velocity. There is a general
agreement that this occurs within 15 mins (min of
15 mins to achieve analgesic effects)

Cryotherapy modalities
1. Ice massage:

Ice massage
Cools more rapidly than an icebag (used mainly
where some stretching is indicated)
Applied in circular or longitudinal pattern
overlapping previous stroke
Applied for 1515-20 mins
Continued till patient goes through the 44-stage
process
Skin should be numb to fine touch

Cryotherapy modalities
2. Hydrocollator packs:

Hydrocollator pack

Pack covered with a towel to limit loss of cold

Not as quick owing to the toweling
Time required for 44-stage around 20 mins
Comfortable properly positioned patient
Used for larger areas eg back

Cryotherapy modalities
3. Ice packs:

Ice packs

Indicated in acute stage of injury as to prevent

additional swelling postpost-exercise
Ice packs believed to function better than gel packs
Applied directly to the skin and held in place by
moist wrap
Can be moulded on body segment
Cubed ice needs to be secured well

Cryotherapy modalities

4. Cold spray:

Cold spray

Topical vapocoolant acting as a counterirritant to

block pain impulses of muscles in spasm
Does not provide adequate penetration
Indicated when stretching of injured part is also
desired
Easy and quick to use
Effective in: myofascial trigger points, LBP, stiff
necks, shoulder bursitis, spasm associated with OA,
ankle sprain, tight hamstring and others.

Cryotherapy modalities
5. Cold whirlpool:

Cryotherapy modalities
Most intense application of cold of listed techniques
Used in acute and subacute conditions in which
exercise of injured part is desired
Temperature around 1010-12 degrees (total body 20
20-25 degrees)
Time 55-15 mins
Maintain significant temperature reduction post
treatment
Can include the massaging of water flow

Cryotherapy modalities
6. Ice immersion:

Ice immersion

Ice buckets are the commonly used by PRM staff

Immersion maintained till desired results are achieved
Controls postpost-traumatic oedema but may be subject to
gravity dependent positions
Cold pain may be quite considerable compared to eg
cold packs

Cryotherapy modalities
7. CryoCryo-cuff:

Cryo--cuff
Cryo
Uses cold and compression simultaneously
Used post acute trauma and post surgery
Nylon sleeve connected to a cooler
Cold water flows into the sleeve from the cooler
Pressure in cuff increaes when cooler elevated
Drawback is that the water must be rechilled in the
cuff when the water gets warmer
Portable, easy to use and inexpensive

Cryotherapy modalities
8. Contrast baths:

Contrast baths
Cold and hot immersions are alternated
Usually 5 cold and 5 warm immersions
Usually a 1:3 ratio for around 20 mins
Vasoconstriction alters with vasodilatation
Used in subacute swelling, gravitygravity-dependent
swelling, delayed onset muscle soreness and to
reduce joint stiffness

Cryotherapy modalities
9. Cryokinetics:

Cryokinetics
Combines cryotherapy with exercise
Goal of cryokinetics is to numb injured part to a point
of analgesia and then working on ROM through
progressive active exercise
Ice immersion, cold packs or ice massage is used
Exercise should be painpain-free and progressive in
intensity concentrating on flexibility and strength

Combination therapy
Cryokinetics
Can also be used with phonophoresis with better antiantiinflammatory result
In muscle spasm accompanying muscle strain
cryotherapy can be used in conjunction with low
frequency electrical stimulation

Complications
Frostbite:
Defined as freezing of body part with tissue
temperatures below 0 degrees
Symptoms initially include tingling and hyperaemia;
then pallor and numbness indicating vasoconstriction
has occurred and blood is no longer circulating
superficialy
Occurrence is rare if procedures are followed
Increased incidence with circulatory insufficiency
If suspected, the body part should be immersed in hot
water at 3838-40 degrees

THANK YOU!