CRYOTHERAPY

Aarti Sareen
MSPT (honours)
• Cryotherapy or ice therapy is the application
of cold to the body tissues after injury. This
practice is as old as medicine itself.

• Nowadays, local cold application may be

applied by the use of various forms of ice or
frozen gel packs, or by evaporation of volatile
fluids from the skin. Often skin temperature is
reduced to 10 C°.
 Physical Principles
• When ice is applied to the skin, heat is conducted
from the skin to the ice in order to melt it.
• To change its state, ice requires considerable
energy that is known as latent heat of fusion.
• A specific amount of energy required to change
the solid form of a particular substance into a
liquid, or the liquid into a gas. This energy is
called Latent Heat and is the energy required to
change of state.
 Factors affecting heat loss
• Temperature changes in the tissues will depend on
both the rate and amount of heat energy removed.
• The colder the application the greater the heat loss
from the tissue.
• In general , water filled tissue, such as muscle, have a
high thermal conductivity compared to fat or skin. Thus
the cooling of deeper tissue depend on the nature of
overlying tissue.
• The amount of energy loss is clearly dependent on
length of time of cold application.
• Larger the area the more heat energy is lost.
 Physiological Effects of Cold Application

• Circulatory Response
• The initial skin reaction to cooling is an attempt to preserve
heat. It is accomplished by an initial vasoconstriction. This
haemostatic response has the effect of cooling of the body
part.
• After a short period of time, the duration depends on the
area involved, a vasodilatation follows with alternating
periods of constriction and dilatation. This reaction of
“hunting” for a mean point of circulation is called “Lewis’s
Hunting Reaction”.
• During the vasodilatation, the arteriovenous anastomosis is
closed, thus causing an increase blood flow through the
capillaries. This is beneficial in the treatment of swelling and
tissue damage.
Lewis’s hunting reaction

Hunting response A
reflex increase in
vasodilatation
that occurs in
response to cold
approximately 15
minutes
into the treatment.
• The initial vasoconstriction is often used to limit the
extravasations of blood into the tissues following
injuries (e.g. sports injuries). Ice therapy is then
usually followed by some forms of compression
bandage.

• The alternate periods of vasoconstriction and

vasodilatation affect the capillary blood flow and it is
across the capillary membrane that tissue fluid can
be removed from the area and returned in the
systemic circulation. Increased circulation allows
more nutrients and repair substances into the
damaged areas.
• Thus ice therapy is very useful in removing
swelling and accelerating tissue repair. i.e. ice
cubes massage may be used to accelerate the
rate of repair of pressure sores.
• The reduced metabolic rate of cooled tissues
allows cooled muscle to contract many more
times before fatigue sets in.
 2. On metabolic rate

• 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.
• The actual change is about one eighth for each
1˚C.
 3.Neural response/peripheral nervous system

• The skin contains primary thermal receptors. Cold receptors

are several times more numerous than warm receptors. The
cold receptors respond to cooling by a sustained discharge of
impulses, the rate of which increases with further cooling.
• The rate of conduction of nerve fibers in a mixed (motor and
sensory) peripheral nerve is reduced by cooling. The first
fibers affected by gradual cooling are the A fibers (myelinated)
and eventually at very low temperatures the B and C fibers
(non-myelinated) are affected.
• Synaptic transmission can also be delayed.
• This effect is helpful in treating pain and hypertonicity.
 4.On motor system
• Muscle strength is seen to diminish on cooling
the limb in water at 10-15 C probably because
of its effect on viscosity and metabolic rate.
• But there are evidences that the strength
increases over the original value about an
hour or so after cooling has ceased.
 Excitatory Cold Mechanism

• When cold is applied in an appropriate way on the

skin, ice can be used to increase the excitatory bias
around the anterior horn cell.
• Combined with other forms of excitation
(brushing, tapping,…) and with the patients’
volitation, this can often produce contraction of an
inhibited muscle (only with intact peripheral nerve
supply).
• This effect can be used when muscle are inhibited
postoperatively or in the later stages of regeneration
of a mixed peripheral nerve
• These structures are fairly deep and it would take several
minutes to produce a sufficiently low temperature to affect
them.
• As it was clinically demonstrated that the reduction of spasm
and spasticity occurs within 30 seconds of ice application, the
reaction to cooling can only be at the superficial tissues at the
skin.
• The skin stimulus produced by cold must have an effect on the
general level of excitation and inhibition in the region of the
anterior horn cells.
• Once spasm and spasticity have been reduced, more long-
time treatment is given in order to sustain the condition. In
the case of spasm, active movements are used to break down
the vicious circle of pain-spasm-more pain- more spasm.
• With spasticity, the technique will depend upon the
preference of the physical therapist.
 Uses of Ice Therapy

• Reduces pain.
• Reduces spasticity.
• Reduces muscle spasm.
• Reduces swelling.
• Promote repair of the damaged tissues.
• Provide excitatory stimulus to inhibited
muscles.
• Used in strength training.
 Reduction of Pain

• Pain reduction is one of the major effects of ice application

which has been used for many years.
• The probable mechanism is that by the stimulation of cold
receptors, impulses will be send back which will pass into the
posterior root of the spinal cord. These impulses, arriving
through large diameter nerves, effectively block out any other
(pain) impulses attempting to access the spinal cord (pain gate
theory).
• This reduces the pain temporarily. For permanent pain
relief, positive physiotherapy (strengthening, mobilization) has
to be given during this period of transient pain relief.
 Reduction of Spasticity

• Spasticity is the pathological state of

increased muscle tone resulting from damage
to the upper motor neurons. The small
anterior horn cell from the higher control of
extrapyramidal system and fires
spontaneously at an increased rate. The net
result of this is ultimately to increase tone in
the extrafusal muscle fibers, when the
hypertonic spastic state appears.
• Spasm is a normal response to injury or pain
and is manifested as an increase in muscle
tone in a specific area with the apparent aim
of limiting movement and further damage.
However the amount of spasm is often
exceeding and the sustained contraction of
muscles will in turn start to produce
pain, often resulting then in more 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.
 Indications
• Acute pain
• Chronic pain
• Acute swelling (controlling hemorrhage and edema)
• Myofascial trigger points
• Muscle guarding
• Muscle spasm
• Acute muscle strain
• Acute ligament sprain
• Acute contusion
• Bursitis
• Tenosynovitis
• Tendinitis
• Delayed onset muscle soreness
 Contraindications
1. Impaired circulation (i.e., Raynaud’s
phenomenon)
2. Peripheral vascular disease
3. Hypersensitivity to cold
4. Skin anesthesia
5. Open wounds or skin conditions (cold
whirlpools and contrast baths)
6. Infection
 Possible effects are due to…..
• The effects of cryotherapy seen are mainly
due to
• Reducution in muscle damage markers:
• Creatine kinase
• Lactate dehydrogenase
• Myoglobin
• Immune markers (leukocyte & neutrophils)

• Reduce muscle soreness rating

• Reduce muscle fatigue rating
 Techniques of Application of Cryotherapy

• The way which ice is applied will vary according to

the required effects.
• It may be applied in the following ways:
– Ice towels
– Ice packs
– Immersion
– Ice cube massage
– Cold compression units
– Ice spray
– Contrast bath
 Time of application of various tech.
• The time required for the sequence varies, but
several authors indicate cryotherapeutic effect
sequences occurs within 5–20minutes.
• After 12–15 minutes the hunting response is
sometimes demonstrated with intense cold (10°
C[50° F]). Thus, a minimum of 15 minutes are
necessary to achieve extreme analgesic effects
 Ice packs

•Simple cold packs

•Silica gel packs
•Endothermic
reaction /chemical
cold packs.
 Ice towel

•Wet towel is used

•Ice towel need to be
replaced after 2-3 min.
and total 20 min .of
treatment can be
given.
•Useful in treating
muscle and allows
movement to be
performed.
 Immersion

•Simple immersion
•Whirlpool immersion
 Ice cube massage

•Slow circular motion for 5-10 min. During

This time the patient will feel cold, burning
And then aching sensation before the part
Become numb.
•Short strokes should be given.
 Cold compression unit

Cold water is circulated in a sleeve which

Is put over the limb and part of it is inflamed
At intervals.
 Cold/ Ice sprays

•Ethyl chloride was originally used but

it is highly inflammable an thus posses
some risks.
•Fluorimethane is now used widely as
it is non inflammable.
• The liquid is sprayed on to the area
to be cooled in series of stroke of
about 5s each with a few seconds
interval between each.
•The nozzle is held at the angle of 45
or right angle from the skin surface.
 CRYOTHERAPY IN SPORTS
• ACUTE PHASE:
• In acute phase of injury either on field or
while exercise session the cryotherapy in form
of either direct application of cold packs or
cold spray is widely used.

• Cryotherapy is given for atleast 72 hours from

injury but it provides best results within 48
hours of injury or acute conditions.
 Rehabilitative phase

• Cryokinetics
• Cryostretch
 Cryokinetics

Combination of cold application and

active exercise
 Why Cryokinetics?

• Cold decreases pain, which

– Facilitates active exercise
• Exercise
– Reduces swelling (dramatically)
– Promotes healing and return to function
 Cryokinetics: Disadvantages

• Pain during initial session

• Cold can be messy.
 Cryokinetics: Indications

• Sprains—dynamite treatment
– Ankle (especially)
– Fingers
• Strength training
 Cryokinetics: Contraindications

• Any exercise or activity that causes pain

• Use of ice on a patient who is hypersensitive
to cold
 Cryokinetics: Precautions

• Use pain as a guideline.

– Warn patient not to gut out pain.
• Don’t allow patient to limp.
• May be an increase in pain 4–8 hr after
treatment
 Principles of Cryokinetics Exercise

• All exercise should be active.

• Performed by the patient
• Exercise must be graded
• Begin with range of motion exercises.
• Progress through increasing levels
of difficulty.
• Full sport activity is final level.
 Principles of Cryokinetics Exercise:
Example (cont.)

• Non-weight-bearing ROM
– Plantar flexion
– Dorsiflexion
– Inversion
– Eversion
– Circumduction
Principles of Cryokinetics Exercise:
Example (cont.)

• Weight-bearing ROM
– Stand up.
– Shift weight
from foot to foot.
– Gradually increase
weight on injured limb.
 Cryostretch for muscle injuries
• Most ( strains and contusions)result in muscle
spasm or tightness.
• Many mild muscle pulls are actually muscle in
spasm rather than torn muscle fiber.
• Reduce spasm with cryostretch.
 Rehabilitation goal

• Promote healing, if tissue torn.

• Control pain
• Reduce spasm
• Control neural inhibition
 Rehabilitation goals (cont.)

• Reset central control through

aggressive, progressive reorientation of full
function.
• Develop muscle strength.
• Promote other phases of rehabilitation.
Cryostretch: Application Parameters
• Three sets
– Numb with ice then activity
• Activity consists of two 65 sec bouts of
exercise with 20 sec rest between bouts
• 65 sec bout
– Stretch muscle to limits and hold 20 sec
– Three static stretches, interspersed with
maximal isometric contraction (hold–relax)
Cryostretch: Application Parameters
(cont.)
– Example exercise bout
• 20 sec static stretch
• 5 sec isometric contraction
• 10 sec static stretch
• 5 sec isometric contraction
• 10 sec static stretch
• 5 sec isometric contraction
• 10 sec static stretch
Cryostretch: Application
Parameters (cont.)
• Numb muscle (20 min max)
• 65 sec stretch–contraction
• 20 sec rest
• Repeat 65 sec stretch–contraction
• Renumb
• Two more stretching bouts (20 sec rest)
• Renumb
• Two more stretching bouts (20 sec rest)
 Combined Cryostretch and
Cryokinetics

• Begin and end with stretch

• Begin cryokinetics exercises with manually
resisted muscle contractions (6-10) through a
full ROM.
• Use DAPRE technique for further progression.
Combined Cryostretch and
Cryokinetics (cont.)

Progress through all phases of rehabilitation using

progressive functional activities.
 Dangers of cryotherapy
• Frost bite
• Nerve palsy
 Severe Frostbite of the Knees After Cryotherapy
Charles K. Lee, MD; Jeff Pardun, MD; Rudolf Buntic, MD; Mark
Kiehn, MD; Darrell Brooks, MD; Harry J. Buncke, MD
Orthopedics January 2007 - Volume 30 · Issue 1:

• A case report showing severe frost bite in 53

years old male, post op of patellar tendon

Frostbite of the Feet After Cryotherapy: A

Report of Two Cases
William C. Brown, MD
, David B. Hahn, MD
 Cryotherapy and nerve palsy, David Drez, JR, MDDonald C.
FaustJ. Pat Evans
doi: 10.1177/036354658100900414

• Ice application is one of the most extensively

used treatments for athletic injuries. Frostbite
is a recog nized danger. Five cases of nerve
palsy resulting from ice application are
reported here. These palsies were temporary.
They usually resolve spontaneously with out
any significant sequelae. This complication can
be avoided by not using ice for more than 30
minutes and by guarding superficial nerves in
the area.
 Whole-body cryotherapy in athletes.
Banfi G, Lombardi G, Colombini A, Melegati G.
Sports Med. 2010 Jun 1;40(6):509-17

• A peculiar form of cold therapy (or stimulation) was proposed 30

years ago for the treatment of rheumatic diseases. The
therapy, called whole-body cryotherapy (WBC), consists of exposure
to very cold air that is maintained at -110 degrees C to -140 degrees
C in special temperature-controlled cryochambers, generally for 2
minutes
• In sports medicine, WBC has gained wider acceptance as a method
to improve recovery from muscle injury. Unfortunately, there are
few papers concerning the application of the treatment on athletes
• Widely recommended for the treatment of arthritis, fibromyalgia
and ankylosing spondylitis.
• The treatment does not enhance bone marrow production and
could reduce the sport-induced haemolysis.
Bone remodelling biomarkers after whole body cryotherapy (WBC) in elite
rugby players.
Galliera E, Dogliotti G, Melegati G, Corsi Romanelli MM, Cabitza P, Banfi G.
Injury. 2012 Sep 20. pii: S0020-1383(12)00368-3

• Whole body cryotherapy (WBC) consists of a brief

exposure to extreme cold air (-110°C) in a controlled
chamber and it is applied in sports medicine to improve
recovery from musculoskeletal trauma. The aim of this
study is to better define the beneficial effect of WCB on the
musculoskeletal system of athletes, in particular on bone
remodelling. Remodelling osteoimmunological biomarkers
OPG, RANKL and RANK were measured after WBC
treatment in 10 male rugby players randomly selected from
the Italian National team. OPG(osteoprotegeric) levels
were increased significantly, supporting the view that
WBC induces an osteogenic effect. Further studies
evaluating the effect of WBC on bone metabolism are
desirable.
 Pre-cooling and sports performance: a meta-analytical review.
Wegmann M, Faude O, Poppendieck W, Hecksteden A, Fröhlich M, Meyer T.
Sports Med. 2012 Jul 1;42(7):545-64

• Pre-cooling can effectively enhance

endurance performance, particularly in hot
environments, whereas sprint exercise is
barely affected. In particular, well trained
athletes may benefit in a typical competition
setting with practical and relevant effects.
With respect to feasibility, cold drinks, cooling
packs and cooling vests can be regarded as
best-practice methods.
 Should athletes return to sport after applying ice? A systematic review of
the effect of local cooling on functional performance.
Bleakley CM, Costello JT, Glasgow PD.
Sports Med. 2012 Jan 1;42(1):69-87

• The current evidence base suggests that athletes

will probably be at a performance disadvantage
if they return to activity immediately after
cooling. This is based on cooling for longer than
20 minutes, which may exceed the durations
employed in some sporting environments. In
addition, some of the reported changes were
clinically small and may only be relevant in elite
sport. Until better evidence is
available, practitioners should use short cooling
applications and/or undertake a progressive
warm up prior to returning to play.
 References
• Clayton’s electrotherapy,9th edition- Sarah &
Bazin- W.B Sunders.
• John low &Reed: Electrotherapy
Explained,Butterworth.
• Lehman- therapeutic heat and cold; ch.14
application procedure.- William & Wilkins.
• William E.Prentice: Therapeutic modalities in
Sports Massage- Mosby.
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