01 96-601 1/83/0502-0066$02.

00/0
THE JOURNALOF ORTHOPAEDIC AND SPORTSPHYSICALTHERAPY
Copyright O 1983 by The Orthopaedic and Sports Physical Therapy Sections of the
American Physical Therapy Association

Review of Physiological Effects of

Cryotherapy
MICHAEL ANDREW KOWAL, PT

The purpose of this work is to provide the physical therapist with the research-
documented conclusions that he would find if he were to review the literature on
the physiological effects of cold therapy. The conclusions are that the results of
the studies reviewed were consistent in describing reductions in musculoskeletal
pain, spasm, connective tissue distensibility, intramuscular temperature, nerve
conduction velocity, and spasticity (except the initial seconds of application).
Other conclusions are that the results of the studies reviewed were inconsistent in
describing the changes in swelling, blood flow, heart rate, blood pressure,
intraarticular temperature, rheumatoid arthritis, monosynaptic reflex, and the
Downloaded from www.jospt.org at on March 17, 2023. For personal use only. No other uses without permission.

muscle spindle.
Copyright © 1983 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Cold is a fundamental modality of physical and four demonstrated residual swelling at 24

therapy. Those who strive to use it wisely are
obliged to research it by reviewing the literature,
experimenting with it clinically, and interacting
with their peers. Here an attempt is made to
present an unbiased presentation of the re-
search that has been done on cryotherapy in this
order: gross effects on swelling, blood flow, pain,
spasm, motor performance, connective tissue,
Journal of Orthopaedic & Sports Physical Therapy®
hours postinjury.
In the Masten et al. study5' seven groups of
rabbits with bilateral laboratory-induced tibia1
fractures were studied. One randomly chosen
limb of each rabbit served as a control limb and
was enclosed in a water jacket of 32" C, the
usual temperature of the hindlimb. Four groups
of experimental limbs were enclosed in water

the heart, tissue temperature, visceral function,
cancer, rheumatoid arthritis, and spasticity; and
subtler effects on nerve conduction velocity, the
monosynaptic reflex, and the muscle spindle.
Three objective and controlled studies dealing
with the effect of cold therapy on acute traumatic
edema were found. In the McMaster and Liddle
study,61 the potential of local cooling to reduce
posttraumatic swelling was investigated on rab-
bits. A standard forelimb crush injury was given
to all rabbits in the experiment. Experimental
group one was given forelimb immersion in 30"
C water for the first hour following injury. Group
two was given forelimb immersion in 20' C water
for the first hour following injury. Groups three
and four were given repeated forelimb immersion
in three cycles consisting of 1 hour of immersion
in 20" and 30" C water, respectively, and 1 hour
of exposure to room air. At 24 hours postinjury,
all swelling was gone from the control group.
Group one had less residual swelling after 24
hours than the control group. Groups two, three,
jackets of 5 or 8, 1 0 or 15, 20 or 25, and 10" C,
respectively. The treatment time for the first
three groups was 24 hours, and for group four
was 6 hours. The limbs cooled in 5 or 8, and 10
or 15" C jackets swelled significantly more than
the controls. This did not become evident until 6
hours posttreatment. Those limbs cooled in 20
or 25" C jackets were not significantly different
from the controls. Swelling observed 96 hours
postfracture tended to increase as the tempera-
ture of the water jacket decreased. Cooling in
the group of limbs treated for 6 hours in 10" C
jackets was as effective in reducing edema as
the control water jacket. In the control limbs,
treated at 32" C, there was hemorrhage and
swelling in the deep tissues surrounding the
bone. In the limbs cooled to 15" C or lower, the
deep structures were similar to those of the
control limbs, but the subcutaneous tissue was
also markedly swollen.
Farry and renti ice^^ used the radiocarpal lig-
ament of the live domestic pig as an experimental
 JOSPT September/October 1983 EFFECTS OF CRYOTHERAPY
model to examine the effects on inflammation of
a pack consisting of finely crushed ice in a plastic
bag applied over the ligament, held in place by
a sphygmomanometer cuff at 106 newtons per
square meter. The cuffs and ice pack were re-
moved after 20 minutes and were reapplied 1
hour later for a further 20 minutes Forty-eight
hours after injury, the ice- and compression-
treated limbs were more edematous than those
not treated with ice and compression, but the
inflammatory reaction within the injured ligament
itself, including microscopic evidence of edema
in the injured ligament, was reduced.
Studies of the effect of local application of
cold on blood flow varied considerably. Five
studies dealt with venous occlusion plethysmog-
Downloaded from www.jospt.org at on March 17, 2023. For personal use only. No other uses without permission.
raphy. Abramson et a1.2 immersed both hands of
his subjects into 1 1-1 4" C water baths. After 25
minutes of immersion, blood flow had decreased
by 83%. The subjects' entire bodies were then
warmed, except the hands in the cold water
bath, with hot packs for 33 minutes. Blood flow
Copyright © 1983 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
then became 91% of the pretreatment blood
flow. Clarke and Helloni4 immersed the forearm
for 30 minutes in water at 10, 18, 26, 34, and
42" C while either sustained or rhythmic exercise
was done. The .more the cooling, the more
marked the reduction in postexercise hyperemia
produced by sustained contractions. For the
rhythmic exercise at 30 cycles per second, the
hyperemic effect was unaltered by cooling, but
Journal of Orthopaedic & Sports Physical Therapy®
at 60 cycles per second there was a marked
increase in the amount of hyperemia at 18" C.
Knight and L ~ n d e r e emeasured
~~ blood flow
to the uninjured ankle with a repeated measures
design of heat packs, cold packs, control, alter-
nating heat and exercise, alternating cold and
exercise, and alternating no treatment (control)
and exercise, for 45 minutes. Blood flow was
significantly greater during heat applications
than for either cold or control. Blood flow de-
creased during cold applications. Exercise ap-
peared to supersede the effects of cold on blood
flow.
Clarke et a1.I6 measured blood flow to the
forearm during 45 minutes of immersion in water
at 1, 6, and 10" C. In forearms treated in both
the 1 and 6" C baths, there was a gradual
increase in blood flow throughout the 45-minute
treatment time, more for the forearms treated in
1 C water than for those treated in the 6" C
water. Those forearms that were treated in the
10" C water demonstrated inconsistent changes
67
in blood flow. Keating40reported two significant
findings. First he reported that Greenfield and
shepherd2' wrote that venous occusion pleth-
ysmography was not a valid method of measur-
ing blood flow in cold extremities. Second, he
reported that the magnitude and timing of vaso-
dilitation in one digit submerged in 0 " C water
depended upon the temperature of the rest of
the body and the subject.
Other reports on blood flow did not involve
plethysmography and included Virtue,77 who
found that clotting time was increased by cold.
LichtS4described a phenomenon whereby cold-
induced vasoconstriction spread to adjacent
body parts. Some authors described a hunting
reaction in which cutaneous blood flow wavered
between vasoconstriction and vasodilitation.
Knight et a1.43 saw it occur in the distal two
phalanges of the third digit of the hand when in
1.5" C water. Vasodilitation occurred after ap-
proximately 25 minutes of cold application. He
did not find the hunting reaction to occur in the
ankle. The Abramson et a1.2 study reported that
a hunting reaction occurred in the hand also.
LichtS4stated that in cold conditions in which the
skin temperature dropped below 10" C for any
length of time, the hunting reaction caused re-
placement of general skin vasoconstriction
about every half hour by a distinct skin vasodili-
tation lasting 10-1 5 minutes. Guyton3' reported
that as skin temperature approached 15' C,
more vasoconstriction occurred in the cutaneous
vessels. Vasodilitation occurred below 15" C,
reaching maximum at O0 C.
Besides the plethysmography studies, few
studies encountered measured cold's effect on
blood flow in joints or in tissues other than the
skin. The Cobbold and Lewis studyi8 showed
that cold applied to the knee joint of a dog
caused vasoconstriction and decreased intraar-
ticular temperature.
Clinically, cold has been demonstrated to be
effective in relieving pain in certain situations.
Grant2' reported treating 7000 outpatients with
ice massage of sufficient duration to cause
numbness (5-7 minutes), followed by range of
motion and mobilization exercises. He reported
that 80% achieved "a predictably rapid and sat-
isfactory treatment" with regained function using
only this treatment in less than three formal
treatments.
Chambersii treated 23 patients with a variety
of musculoskeletal and neurological disorders
 WAL
for 20 minutes with towels soaked in 35-40" C
ice water. After one to several treatments, pain
was sufficiently decreased or eliminated in 74%
of those patients with pain. Range of motion
improved in 94% of the patients limited in range
of motion, and spasticity was decreased in 67%
of patients with spasticity. Numerous other re-
ports confirmed the pain-relieving ability of a
treatment involving cold a p p l i c a t i ~ n . ~ ~ . ~ ~ 'strength
Way-
lonissO reported surface anesthesia after 4.5
minutes of ice massage over the calf. Skin tem-
perature had decreased 18" C after 5 minutes.
There were many testimonials to the effective-
ness of local muscle cooling on painful spasms
with one or a few treatments.28'33'45.63.69.73374
Many of these involved the use of a vapo-coolant
and a spray-and-stretch
Downloaded from www.jospt.org at on March 17, 2023. For personal use only. No other uses without permission.
Mennel163emphasized that the effectiveness of
cold treatment for spasm was that the cooling
decreased sensation, allowing the recovery of
range of motion and the stretching out of the
spasm. Nielson6' gave this same rationale for
Copyright © 1983 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
myofascial pain.
The literature abounds with reports of the ef-
fects on motor performance of cold application.
McGownGOcompared the effects of a 28" C ice
massage for 5 minutes on the anterior thigh.
Significantly higher (7%) maximum isometric
quadriceps contractions were found following
the ice massage than massage with a wooden
block. Edwards et a1.22 measured quadriceps
Journal of Orthopaedic & Sports Physical Therapy®
strength 2 minutes after entire leg immersion in
12, 26, and 44" C water for 45 minutes. For legs
given baths in all three temperatures, endurance
time for a single contraction was reduced. En-
durance was significantly better in legs im-
mersed in cold than warm baths.
Clarke and StelmachI3 immersed arms in 10"
C water for 1 0 minutes, then had the subjects
perform a maximum 2-minute handgrip in the
water, then monitored recovery while immersed
for another 1 0 minutes. Cold caused a significant
reduction in initial strength of 11% measured
after 1 0 minutes of immersion, and an increase
in final strength of 13% measured after 20 min-
utes of immersion.
Grosse30immersed the forearm in 10" C water
for 8 minutes and found that posttreatment
strength was 11% less than the pretreatment
strength. Oliver et aL7' put the leg in 10" C water
for 30 minutes. A definite relationship was found
between intramuscular temperature and plantar
flexion strength. Strength was decreased im-
mediately posttreatment. It steadily increased,
JOSPT Vol. 5,No. 2
beginning at 30 minutes posttreatment, and
reached 133% of pretreatment levels at 180
minutes posttreatment. The greatest increases
in plantar flexion strength occurred simultane-
ously with the greatest gains in posttreatment
intramuscular temperature. Oliver and John-
son's70 subjects stood midthigh in 12" C water
for 3 0 minutes. Immediate posttreatment
~~ decreased 2% from pretreatment
levels. At 40 minutes posttreatment, strength
was 122% of pretreatment, peaked 8 0 minutes
posttreatment at 124%, and was still increased
116% 180 minutes posttreatment. A control
group had the same pattern of changes, only the
magnitude was less.
Johnson and eider^' used a 30-minute fore-
arm bath of 10-1 5" C. Immediate posttreatment
strength was diminished from pretreatment
strength, equal to pretreatment strength at 20
minutes posttreatment, and by 80 minutes post-
treatment was significantly greater than any pre-
vious measurements, and remained so through-
out the remaining 100 minutes of the test. Foldes
et al.25worked with an in vitro rat nerve. Muscle
performance at low (0.1 cycles per second) but
not at high (50 cycles per second) rates of direct
and indirect stimulation especially, was improved
when the temperature was lowered from 37 to
17" C.
Lind and S a m ~ e l o f freported
~~ that a single
contraction to fatigue was longer at water bath
temperatures of 18" C than at 34' C. Clarke et
a1.15 immersed the forearm for 3 0 minutes in
different water baths of temperatures ranging
from 2 to 42" C. The duration of 1 / 3 maximal
contractions was longest for an 18" C bath. In
another study, Clarke12 had his subjects first
perform a 2-minute maximal contraction, then
put their hand in 10' C water for 1 0 minutes. He
found that recovery to pretreatment strength
levels took 13% longer than recovery of a control
group.
Clendenin and Szumskii7 examined single mo-
tor unit control in the biceps brachii. Enough
cutaneous icing was applied to produce an even
erythema (1 -2 min). The result of icing was to
facilitate a trained motor unit. Wolf and Letbet-
ters3 worked with the shaved gastrocnemius-so-
leus of decerebrate cats. An 8.6-square centi-
meter thermoelectric cooling module reduced
skin-interface temperatures to as low as 10" C
at a rate of approximately 1 ' C per second. All
the cats showed a reduction in integrated elec-
tromyographic activity following 1-5 seconds of
 JOSPT September/October 1983 EFFECTS OF CRYOTHERAPY
cutaneous cold stimulation. When cold was re-
moved, electromyographic activity showed a
large transient increase 1-1 0 seconds after re-
moval, before returning to precooling control
levels. However, individual motor unit response
to skin cooling varied. These effects occurred
without significant reduction in intramuscular
temperature.
Two studies dealt with the effect of cold appli-
cation on connective tissue. The Warren et al.
study7' of in vitro rat tendon demonstrated that
higher therapeutic temperatures at relatively
light loads produced the greatest elongations
with the least damage. The Lehmann et al.
study5* used in vivo rat tail tendon. It tested at
normal in vivo temperature for rat tail (25' C)
and at 45" C. It was found that the better way to
Downloaded from www.jospt.org at on March 17, 2023. For personal use only. No other uses without permission.
achieve length increase was by stretching either
during or after heating. Lehmann et a1.52 ex-
plained that since reorganization of connective
tissue was thought to occur during the cooling
period, subsequent to the application of stretch
Copyright © 1983 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
and heat, load was maintained while cooling the
tendon. This technique was found to be more
effective in producing a lasting length increase
than the applications in which the load was re-
moved at the end of the heat period.
Cold application has been reported to have
varying effects on the heart and on blood pres-
sure. Wayloniss0 reported no change in blood
pressure or pulse with a 5-minute ice massage
Journal of Orthopaedic & Sports Physical Therapy®
over the calf. Lorenze et a1.57 applied towels
which had been soaked in ice water on the
shoulder for 10 minutes. No significant clinical
or electrocardiographic changes were detected.
In one out of 25 subjects with coronary artery
disease, there were changes. Glaser and Whit-
discovered a habituation effect with hand
cooling in 4 " C water as measured by a decrease
in reactive blood pressure and heart rate rises
over a 24-hour period. Murphy67 reported that
the effect of cold on the heart depends on the
duration and intensity of the cold stimulus. Vir-
tue77 described effects on respiration of cold
immersion baths.
Much literature dealt with objective tempera-
ture changes within various tissues. Regarding
changes in intraarticular temperature, the re-
ports were few. Borken and Bierman" applied
50-1 00 grams of ethyl chloride solution along a
5-inch diameter section of the knee in a 15-30
minute period. Knee joint temperature decreases
ranged from 1.9 to 3.2" C, while skin tempera-
ture fell from 15-27" C. Downey2' cited Hor-
69
~ a t as h ~reporting
~ that the temperature of the
knee joint boney structures may be reduced
when a superficial form of heating such as hot
packs was applied to the joint, or increased with
a cold application. In the Cobbold and Lewis
study," in which cold was applied to the knee
joint of dogs, cold caused vasoconstriction and
decreased intraarticular temperature. Wakim et
al.78 applied ice packs of 6-1 2" C to the knee
and leg of dogs for 1 hour, which produced
marked reduction in joint temperature of 18.4"
C.
Cold application inevitably reduced skin tem-
perature. Four studies6~7~75~80 involved icing the
calf. Two studies75780 produced mean skin tem-
perature drops of 11-1 2" C in 5-10 minutes,
while two617 produced a 6" C drop during a 2-
hour ice application. In the Knight et al. study,43
it took the fingers studied 30 minutes to regain
pretreatment temperature after 40 minutes of
immersion in 1.5" C water. Ankles took greater
than 30 minutes to regain pretreatment temper-
ature. At 5 minutes into treatment, fingers had
cooled to 2.8" C, and ankles to 7.4" C. ZankelE4
produced a mean decrease of 22" C in elbow
temperature after a 5-minute ice pack. Borken
and Bierman" used ethyl chloride to cool the
calf or thigh 15-27' C. ~ o e s 'used ice water
towels on hemiplegics' quadriceps for 7 minutes
to cause a mean drop of 13" C.
All the studies reporting effects on intramus-
cular temperature (IMT)~-8,10.15,22.32,39.46.58,62.
71.80-82 found that IMT either remained un-
changed or decreased. A variety of cold modal-
ities were used. The greater the depth at which
IMT was measured, the less the decrease. In
some cases39.81IMT could remain decreased for
minutes to hours after treatment. Also, the
greater the depth of IMT measurement, the
longer the time required of cold application to
affect maximum temperature ~ h a n g e ~ and ?~~'~,
the less the magnitude of change." The results
of Waylonis' studys0 are provided in Table 1 as
a representative example of IMT study results.
In a modality comparison study, McMaster et
found ice the superior mode. Where it was
addressed, no response difference with respect
to sex was found." Many of the studies and this
author conjectured variables which could influ-
ence IMT response: mode temperature, area,
blood flow, local metabolic rate, depth of meas-
urement, sympathetic i n t e g r i t ~ , ~modality,
' du-
ration of application, mass to be cooled, validity
and reliability of these studies,58effects of ther-
 70
TABLE 1
Waylonis studPo results. 5- or 10-minute ice massage and
local lidocaine
IMT depth Temperature
Area
(cm) drop ("C)
Thigh, 5-minute ice 0.5
massage 1
2 Studies of cryotherapeutic effects on the
3 monosynaptic reflex found that the amplitude
4 of the monosynaptic reflex in the lower ex-
Thigh, 10-minute ice 0.5
massage 1
2
3 In reviewing the reported effects on the muscle
4 spindle resulting from decreasing IMT, in the
Calf, 5-minute ice mas- 0.5
sage 1
2
3
Downloaded from www.jospt.org at on March 17, 2023. For personal use only. No other uses without permission.
4 But Eldred et
mocouple insertion,42 inactivity of the subject
during the e~periment,~' and the type of subject.
wolfai indicated that local cooling had cooling
Copyright © 1983 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
effects on the contralateral body. No evidence
of an IMT hunting reaction was found by this
author in any of the sources reviewed.
Occasionally, one finds mention in the litera-
ture of other than traditional uses of local cold
application. For example, Murphy67cited studies
indicating that ice placed on the abdomen can
influence the gastrointestinal system and other
organs, and cited other studies indicating that
Journal of Orthopaedic & Sports Physical Therapy®
cancer tissue does not tolerate cold as well as
normal tissue. Other uses for local application
are admittedly inadequately addressed by this
present discussion. An example is the use of
cold for rheumatoid a r t h r i t i ~ . ~ ~
The numerous spasticity studies, while using
various cryotherapeutic modes, were quite con-
sistent in their results. Two of them32776 found
initial increases in spasticity with cold applica-
tion. All studies encountered by this
author4.7.32.34,37,41.46.47,65,66 reported a general
decrease in spasticity. Four7.32,4'~a6 noted the
delayed return of spasticity after treatment had
ceased. Two studies4334 mentioned that cold was
not effective for all the spastics upon which it
was used. reported decreased passive
resistance to stretch or increased range of mo-
tion. The Houtz and Blakeley study37 reported
increased function. None of these studies men-
tioned an excessive rebound of spasticity after
or while the effects of cold wore off.
In condensing nerve conduction velocity
studies' results, therapeutic cold decreased mo-
KOWAL JOSPT Vol. 5,No. 2
tOr19. 20,26.35,51.84
and s e n ~ o r y ' nerve
~ ~ ~ con-
~ ~ ~ '
duction velocities in proportion to the amount of
cooling, and approximately linearly.'gs3i Differ-
ent fiber types responded differently in that nerve
conduction velocities decreased fastest for
Group A fibers and slowest for Group C fibers.
tremity either d e c r e a ~ e d ,or~~remained
~ ~ , ~ ~un-
changed.75
Michalski and Seguin cooling from 37
to 24" C had no apparent effect on Group I
fibers, but Group II fibers became more sensitive.
found both Group I and Group
II fibers became less sensitive from 38 to 23O C,
Group I fibers even more so than Group II. In
these two studies, similar temperatures and an-
imals were used. Both did not resemble clinical
settings. The Lippold et a1.56 results disagreed
with both of these studies, indicating that the
isolated spindle in general was most sensitive at
26" C. Only Eldred et al.23 mentioned an effect
on Golgi tendon organ activity, finding that it
decreased with cold. Newton and L e h m k ~ h l ~ ~
measured activity at a different place in the nerv-
ous system than did Michalski and S e g ~ i and n~~
Eldred et al.23Newton and L e h m k ~ h l ' sresults
~~
indicated less reflex and other activity because
the frequency of action potentials in the dorsal
root filaments decreased with decreasing IMT.
CONSIDERATIONS
In considering these studies, some precau-
tions need to be taken. Speculation and extrap-
olation are desirable, but such need to be differ-
entiated from objective results. Studies need to
be controlled and statistically analyzed. Practical
clinical study results need to be viewed together
with basic physiology knowledge and studies.
Generalization can be detrimental if there are
inadequate facts to substantiate it. It is not ac-
ceptable to state that cold decreases blood flow,
diminishes hemorrhage developing after trauma,
decreases edema formation, decreases spasm
and spasticity, and relieves musculoskeletal
pain. It is acceptable, however, to state that
based on research results or personal experi-
ence that cold can do one or some of these
things in this particular situation on this particular
structure with this much cold applied for this
 JOSPT September/October 1983 EFFECTS OF CRYOTHERAPY
much time with this population. It is acceptable
to quote a study only if all pertinent details are
included in that quote. The utility of any treat-
ment may be wholly or partly attributable to
either or both the therapist's or patient's convic-
tion that the treatment he is receiving will be
effective. In examining IMT studies, it is relevant
that a given depth of IMT measurement may be
in different structures for different subjects.
The results of the studies presented in this
paper were summarized by this author. The two
~ t u d i e s ~ ' , on
~ ' swelling in rabbits and one in
pigs" indicated that the right kind of cold can
be effective in decreasing swelling in mechani-
cally traumatized tissues. The wrong kind of cold
can exacerbate swelling. Except for the pleth-
ysmography studies, none of these studies doc-
Downloaded from www.jospt.org at on March 17, 2023. For personal use only. No other uses without permission.
umented changes in blood flow to muscle. This
author wondered what exactly plethysmography
measured. Farry and P r e n t i ~ efound ~ ~ that in-
flammation can be diminished in an injured liga-
ment by using cold and compression. Many stud-
Copyright © 1983 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ies found that a hunting reaction can occur in the
skin. Much writing about the hunting reaction is
based on Thomas Lewis' concerning
changing skin circulation in a finger immersed in
cold water. Cold's effects on swelling and sub-
cutaneous circulation were not clearly estab-
lished by these studies.
It was found that cold could be very effective
for the relief of musculoskeletal pain. It was
Journal of Orthopaedic & Sports Physical Therapy®
found that cold and stretching and exercise were
very effective for relieving painful spasms and
myofascial pain. Studies indicated that cold
could influence muscle performance, often caus-
ing decreased immediate posttreatment strength
and delayed posttreatment strength increases.
The two ~ t u d i e s ~dealing~ . ~ ' with connective tis-
sue indicated that heat and light load worked to
increase length, while cold applied in the
stretched position helped to maintain length in-
creases. Sometimes heart rate and blood pres-
sure were affected by cold. Skin and muscle
temperature decreased with cold application,
and remained decreased for a while after treat-
ment was discontinued. Three of four
s t ~ d i e s ' ~ ~indicated
' ~ ' ~ ~ "that
~ intraarticular tem-
perature dropped in response to cold applica-
tion. No evidence of a hunting response in sub-
cutaneous tissue was found. Cold application
was mentioned as having potential effects on
viscera and as having other-than-traditional
uses. Cold applications were reported to cause
a general decrease in spasticity, though de-
71
crease could be preceded by an initial transient
increase. Return of spasticity posttreatment was
sometimes reported as delayed. Nerve conduc-
tion velocities responded to cold by decreasing
proportionately. Different fiber types were re-
ported to differ in degree of response. Amplitude
of lower extremity monosynaptic reflex de-
creased or remained unchanged. The muscle
spindle was reported to respond to cold, but the
nature of the response varied between reports.
It appeared that response to cold was complex
and dependent on a multiplicity of factors, some
of which were previously listed. It appeared to
this author most appropriate to conclude that the
responses to any one specific application scen-
ario be assessed by clinical experience and by
examining studies which made use of that same
scenario. If studies with the same scenario are
not available, one must be very careful in at-
tempting to apply results of incongruous sce-
narios to the scenario of interest.
Some additional clinical considerations were
made. Often the treatment time for cold was
recommended to be approximately 20 min-
u t e ~ . ~This
, ~ ' author thought that this duration
was likely attributable to reported observed cu-
taneous hunting reaction vasodilitation timing.
Kramer and ~ e n d r ~ described
k~' that if deep
tissue vasodilitation occurred with cutaneous
hunting reaction vasodilitation, then to minimize
the possibility of increasing blood flow to acutely
injured tissue, cold should not be applied for
more than approximately 20-30 minutes at one
time, followed by 20 minutes of rest. This author
questioned the validity of this because deep
tissue vasodilitation was not shown to occur
along with cutaneous vasodilitation. Abraham'
indicated that cold increased muscle blood flow
and facilitated healing for muscle injuries. FOX^^
stated that the persistent effect of cold vasodili-
tation after removal of cold was to cause rapid
rewarming. This may be a clue to treating frost-
bite and hypothermia. LichtS4explained that cold
was believed to be more penetrative than heat
since cold usually decreased blood flow,
whereas heat increased blood flow, and in-
creased blood flow would tend to carry away
heat. Barnes3 listed contraindications for cold
application.
This author also added that an athlete who is
treated on the sidelines should not return to
participation because he is more susceptible to
injury. Muscle performance, nerve conduction
velocity, sensation, and connective tissue flexi-
 72 KOWAL
bility were likely altered by the cold application.
This author recommends that physical thera-
pists be attentive to the documented and un-
documented effects of cold therapy and related
research, so that they can learn to use it to
achieve specific objectives consistently.
SUMMARY
An extensive review of cold study results was
made and a summary of these results was pro-
vided. The consistent findings were reductions
in musculoskeletal pain, spasm, connective tis-
sue distensibility, intramuscular temperature,
nerve conduction velocity, and spasticity (except
upon initial cold contact). The inconsistent find-
ings were effects on swelling, blood flow, heart
Downloaded from www.jospt.org at on March 17, 2023. For personal use only. No other uses without permission.
rate, blood pressure, intraarticular temperature,
rheumatoid arthritis, the monosynaptic reflex,
and the muscle spindle. The physical therapist
should be aware of what has been documented
and whether or not he has a valid reason for
using cold therapy in the manner in which he
Copyright © 1983 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
uses it.
REFERENCES
1. Abraham WM: Heat vs cold therapy for the treatment of muscle
injuries. Athl Train 9(4):177, 1974
2. Abramson Dl, Tuck S, Lee SW, Richardson G. Chu LSW: Vas-
cular basis for pain due to cold. Arch Phys Med Rehabil47:300-
305, 1966
3. Barnes L: Cryotherapy-putting injury on ice. Phys Sportsmed
7(6): 130-1 36, 1979
Journal of Orthopaedic & Sports Physical Therapy®
4. Basset SW. Lake BM: Use of cold applications in management
of spasticity. Phys Ther Rev 38(5):333-334, 1958
5. Behnke R: Cryotherapy and vasodilation. Athl Train 8(3):106.
1973
6. Bierman W: Therapeutic use of cold. JAMA 157:1189-1192,
1955. In Olson JE, Stravino VD: A review of cryotherapy. Phys
Ther 52(8):841-853, 1972
7. Bierman W, Friendlander M: The penetrative effect of cold. Arch
Phys Med Rehabil 21:585-592, 1940. In: Olson JE, Stravino
VD: A review of cryotherapy. Phys Ther 52(8):841-853, 1972
8. Bing JH, Watts N: Effects of cooling on the triceps surae reflex.
Am J Phys Med 42:240-251. 1962. In: Johnson DJ, Moore S,
Moore J, Oliver, RA: Effect of cold submersion on intramuscular
temperature of the gastrocnemius muscle. Phys Ther
59(10):1238-1242, 1979
9. Boes MC: Reduction of spasticity by cold. J Am Phys Ther Assoc
42(1):29-32, 1962
10. Borken N. Bierman W: Temperature changes produced by spray-
ing with ethyl chloride. Arch Phys Med Rehabil 36:288-290.
1955
11. Chambers R: Clinical uses of cryotherapy. J Am Phys Ther Assoc
49(3):145-149, 1969
12. Clarke DH: Effect of immersion in hot and cold water upon
recovery of muscular strength following fatiguing isometric ex-
ercise. Arch Phys Med Rehabil 44565-568, 1963
13. Clarke DH, Stelmach GE: Muscle fatigue and recovery curve
parameters at various temperatures. Res Q 37(4):468-479,
1966
14. Clarke RSJ, Hellon RF: Hyperaemia following sustained and
rhythmic exercise in the human forearm at various temperatures.
JOSPT Vol. 5, No. 2
J Physiol 145:447-458, 1959
15. Clarke RSJ, Hellon RF. Lind AR: The duration of sustained
contractions of the human forearm at different muscle tempera-
tures. J Physiol 143:454-473, 1958
16. Clarke RSJ, Hellon RF. Lind AR: Vascular reactions of the human
forearm to cold. Clin Sci 17:165-179, 1958. In: Knight KL,
Londeree BR: Comparison of blood flow in the ankle of uninjured
subjects during therapeutic applications of heat, cold, and ex-
ercise. Med Sci Sports Exer 12(1):76-80. 1980
17. Clendenin MA, Szumski AJ: Influence of cutaneous ice applica-
tion on single motor units in humans. Phys Ther 51(2):166-175.
1971
18. Cobbold AF, Lewis OJ: Blood flow to the knee joint of the dog:
effect of heating, cooling. and adrenaline. J Physiol 132:379-
383, 1956. In: Olson JE, Stravino VD: A review of cryotherapy.
Phys Ther 52(8):841-853, 1972
19. DeJesus PV. Hausmanowa-Petrusewicz I, Barchi RL: The effect
of cold on nerve conduction of human slow and fast nerve fibers.
Neurology 23:1182-1189, 1973
20. DeJong RH, Hershey WM, Wagman IH: Nerve conduction veloc-
ity during hypothermia in man. Anes 27:805-810. 1966. In:
Mecomber SA. Herman RM: Effects of local hypothermia on
reflex and voluntary activity. Phys Ther 51(3):271-281 , 1971
21. Downey JA: Physiological effects of heat and cold. J Am Phys
Ther Assoc 44(8):713-717, 1964
22. Edwards RHT, Harris RC, Hultman E, Kaijser L, Koh D. Nordesjo
LO: Effect of temperature on muscle energy metabolism and
endurance during successive isometric contractions, sustained
to fatigue, of the quadriceps muscle in man. J Physiol 220:335-
352, 1972
23. Eldred E, Lindsley DF. Buchwald JS: The effect of cooling on
mammalian muscle spindles. Exp Neurol 2:144-157. 1960
24. Farry PJ. Prentice NG: Ice treatment of injured ligaments: an
experimental model. NZ Med J 91 :12-14, 1980
25. Foldes FF, Kuze S, Vizi ES, Deery A: The influence of tempera-
ture on neuromuscular performance. J Neural Transm 43:27-
45,1978
26. Fox RH: Local cooling in man. Brit ~ e Bull d 17(1):14-18, 1961
27. Glaser EM, Whittow GC: Adaptation to cold. J Physiol 136:98-
111, 1957
28. Grant AE: Massage with ice (cryokinetics) in the treatment of
painful conditions of the musculoskeletal system. Arch Phys Med
Rehabil45:233-238, 1964
29. Greenfield ADM, Shepherd JT: A quantitative study of the re-
sponse to cold of the circulation through the fingers of normal
subjects. Clin Sci 9:323-347, 1950. In: Keatinge WR: The effect
of general chilling on the vasodilator response to cold. J Physiol
139:497-507, 1957
30. Grose JE: Depression of muscle fatigue curves by heat and cold.
Res Q 29(1):19-31. 1958
31. Guyton AC: Medical physiology, Ed. 6, Chaps. 29, 72. Philadel-
phia, WB Saunders Co. 1981
32. Hartviksen K: Ice therapy in spasticity. Acta Neurol Scand 38
(Suppl 3):79-84. 1962
33. Hayden C: Cryokinetics in an elderly treatment program. J Am
Phys Ther Assoc 44:l 1, 1964. In: Kelly M: Effectiveness of a
cryotherapy technique on spasticity. Phys Ther 49(4):349-353.
1969
34. Hedenberg L: Functional improvement of the spastic hemiplegic
arm after cooling. Scand J Rehabil Med 2:
35. Henriksen JD: Conduction velocity of motor nerves in normal
subjects and patients with neurological disorders. Thesis. Grad-
uate School of Minnesota. Minneapolis, 1956. In: Mecomber SA,
Herman RM: Effects of local hypothermia on reflex and voluntary
activity. Phys Ther 51(3):271-281, 1971
36. Horvath SM, Hollander JL: The influence of physical therapy
procedures on the intra-articular temperature of normal and
arthritic subjects. Am J Med Sci 218543, 1949. In: Downey JA:
Physiological effects of heat and cold. J Am Phys Ther Assoc
44(8):713-717, 1964
37. Houtz SJ, Blakeley MG: Observations on the effects of cool
baths for patients with multiple sclerosis. Phys Ther Rev
 JOSPT Septernber/October 1983 EFFECTS OF CRYOTHERAPY
39(5):297-299. 1959
38. Johnson DJ, Leider FE: Influence of cold bath on maximum
handgrip strength. Percept Mot Skills 44:323-326, 1977
39. Johnson DJ, Moore S, Moore J. Oliver RA: Effect of cold sub-
mersion on intramuscular temperature of the gastrocnemius mus-
cle. Phys Ther 59(10):1238-1242. 1979
40. Keatinge WR: The effect of general chilling on the vasodilator
response to cold. J Physiol 139:497-507. 1957
41. Kelley M: Effectiveness of a cryotherapy technique on spasticity.
Phys Ther 49(4):349-353. 1969
42. King PG, Reid DG, Mendryk SW: The effect of actively increased
muscle temperature on grip strength. Med Sci Sport 2:172-175.
1970
43. Knight KL. Aquino J. Johannes SM. Urban CD: A reexamination
of Lewis' cold induced vasodilitation in the finger and the ankle.
Athl Train 15:248-250, 1980
44. Knight KL, Londeree BR: Comparison of blood flow in the ankle
Downloaded from www.jospt.org at on March 17, 2023. For personal use only. No other uses without permission.
of uninjured subjects during therapeutic applications of heat,
cold. and exercise. Med Sci Sport Exer 12(1):76-80, 1980
45. Knott M, Barufaldi D: Treatment of whiplash injuries. Phys Ther
Rev 41 :8, 1961. In: Kelly M: Effectiveness of a cryotherapy
technique on spasticity. Phys Ther 49(4):349-353. 1969
46. Knutsson E: Topical cryotherapy in spasticity. Scand J Rehabil
Med 2:159-163, 1970
Copyright © 1983 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
47. Knutsson E, Lindblom U, Martensson A: Differences in gamma
and alpha spasticity induced by the GABA derivative Baclofen
(Lioresal). Brain 96:29-46, 1973
48. Knutsson E, Mattson E: Effects of local cooling on monosynaptic
reflexes in man. Scand J Rehabil Med 1:126-132. 1969
49. Kramer JF, Mendryk SW: Cold in the initial treatment of injuries
sustained in physical activity programs. Can Assoc HPER J
45(4):27-29. 38-40, 1979
50. Lane LE: Localized hypothermia for the relief of pain in muscu-
loskeletal injuries. Phys Ther 51(2):182-183. 1971
51. Lee JM. Warren MP. Mason SM: Effects of ice on nerve conduc-
tion velocity. Physiotherapy 64(1):2-6, 1978
Journal of Orthopaedic & Sports Physical Therapy®
52. Lehmann JF, Masock AJ, Warren CG. Koblanski JN: Effect of
therapeutic temperatures on tendon extensibility. Arch Phys Med
Rehabil 51 :481-487. 1970
53. Lewis T: Observations upon the reactions of the vessels of the
human skin to cold. Heart 15:177-208, 1930
54. Licht S: Therapeutic heat and cold. Chaps. 4, 21. New Haven.
CN. Elizabeth Licht. 1965
55. Lind AR. Samueloff M: The influence of local temperature on
successive sustained contractions. Proceedings of the Physio-
logical Society, 19 January 1957, 12p-13p.
56. Lippold OCJ, Nicholls JG, Redfearn JWT: A study of the afferent
discharge produced by cooling a mammalian muscle spindle. J
Physiol 153:218-231. 1960
57. Lorenze EJ, Carantonis G, DeRosa AJ: Effect on coronary cir-
culation of cold packs to hemiplegic shoulders. Arch Phys Med
Rehabil41:394-399. 1960
58. Lowdon BJ, Moore RJ: Determinants and nature of intramuscular
temperature changes during cold therapy. Am J Phys Med
54(5):223-233, 1975
59. Masten F, Questad K. Matsen A: The effect of local cooling on
postfracture swelling. Clin Orthop 109:201-206, 1975
60. McGown HL: Effects of cold application on maximal isometric
contraction. Phys Ther Rev 47(3):185-192, 1967
61. McMaster WC, Liddle S: Cryotherapy influence on posttraumatic
limb edema. Clin Orthop 150:283-287, 1980
73
62. McMaster WC, Liddle S, Waugh TR: Laboratory evaluation of
various cold therapy modalities. Am J Sports Med 6(5):291-
294, 1978
63. Mennel JM: The therapeutic use of cold. JAOA 74:1146-1157,
1975
64. Michalski WJ, Seguin JJ: The effects of muscle cooling and
stretch on muscle spindle secondary endings in the cat. J Physiol
253:341-356. 1975
65. Miglietta 0: Action of cold on spasticity. Am J Phys Med
52(4):198-205. 1973
66. Miglietta 0 : Electromyographic characteristics of clonus and
influence of cold. Arch Phys Med Rehabil 45:508, 1964
67. Murphy AJ: The physiological effects of cold application. Phys
Ther Rev 40(2):112-115, 1960
68. Newton MJ, Lehmkuhl D: Muscle spindle response to body
heating and localized muscle cooling: implications for relief of
spasticity. J Am Phys Ther Assoc 45(2):91-105, 1965
69. Nielson AJ: Spray and stretch for myofascial pain. Phys Ther
58(5):567-569, 1978
70. Oliver RA, Johnson DJ: The effect of cold water baths on post-
treatment leg strength. Phys Sportsmed 4:67-69, 1976
71. Oliver RA, Johnson DJ. Wheelhouse WW, Griffin PP: Isometric
muscle contraction response during recovery from reduced in-
tramuscular temperature. Arch Phys Med Rehabil 60:126-129,
1979
72. Rocks JA: Intrinsic shoulder pain syndrome. Phys Ther
59(2):153-159, 1979
73. Travell J: Ethyl chloride spray for painful muscle spasm. Arch
Phys Med Rehabil32:291-298, 1952
74. Travell J: Rapid relief of acute "stiff neck" by ethyl chloride
spray. J Am Med Wom Assoc 4(3):89-95, 1949
75. Urbscheit N. Bishop B: Effects of cooling on the ankle jerk and
H-response. J Am Phys Ther Assoc 50(7):1041-1049, 1970
76. Viel E: Treatment of spasticity by exposure to cold. Phys Ther
Rev 39(9):598-599. 1959
77. Virtue RW: Hypothermic anesthesia. Springfield. IL, Charles C
Thomas, 1955. In: Murphy AJ: The physiological effects of cold
application. Phys Ther Rev 40(2):112-115, 1960
78. Wakim KG, Porter AN, Krusen FH: Influence of physical agents
and certain drugs on intraarticular temperature. Arch Phys Med
Rehabil 32:714, 1951
79. Warren CG, Lehman JF, Koblanski JN: Elongation of rat tail
tendon: effect of load and temperature. Arch Phys Med Rehabil
52:465-474. 1971
80. Waylonis GW: The physiological effect of ice massage. Arch
Phys Med Rehabil48:37-42. 1967
81. Wolf ,SL: Contralateral upper extremity cooling from a specific
cold stimulus. Phys Ther 51 (2):158-165, 1971
82. Wolf SL, Basmajian JV: Intramuscular temperature changes deep
to localized cutaneous cold stimulation. Phys Ther 53(12):1284-
1288.1973
83. Wolf SL, Letbetter WD: Effect of skin cooling on spontaneous
EMG activity in triceps surae of the decerebrate cat. Brain Res
91 : I 5 1 -1 55, 1975
84. Zankel H: Effect of physical agents on motor conduction velocity
of the ulnar nerve. Arch Phys Med Rehabil 47(12):787-792,
1966