Cold Cryotherapy Notes

7/23/2019 Cold Cryotherapy Notes

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COLD-CRYOTHERAPY

Cryotherapy, the therapeutic use of cold, has clinical applications in rehabilitation

EFFECTS OF COLD

Hemodynamic effects• Initial decrease in blood flow

• Later increase in blood flow

Neuromuscular effects

• Decreased nerve conduction velocity

• Increased pain threshold

• Altered muscle strength

• Decreased spasticity

• Facilitation of muscle contraction

Metabolic effects

• Decreased metabolic rate

Hemodynamic effects

Initial decrease in blood flow

if cold is applied to the skin, it causes an immediate constriction of the cutaneousvessels and a reduction in blood flow (application is limited to less than 15 to 20 minutes)

Cold causes cutaneous vasoconstriction by both direct and indirect mechanism

Later increase in blood flow

• When cold is applied for longer periods of time (more than 15 min) or when the tissuetemperature reaches less than 10 0C vasodilation may occur. This phenomenon isknown as cold-induced vasodilation (CIVD) and was first reported by lewis in 1930.

• Temperature cycling with alternating vasoconstriction and vasodilation and called islewis hunting response or lewis hunting reaction

• Cold-induced vasodilation is most likely to occur in the distal extremities, such as thefingers or toes, with application of cold for more than 15 minutes at temperatures below 10C.

• Cooling decreases oxygen-hemoglobin dissociation, making less oxygen available to thetissues at lower temperature, cold induced vasodilation is not considered to be aneffective means of increasing oxygen delivery to an area.

Neuromuscular Effect

• Decreasing Nerve Conduction Velocity,

• Elevating The Pain Threshold,

• Altering Muscle Force Generation

• Decreasing Spasticity, And

• Facilitating Muscle Contraction

Decreased nerve conduction velocity

• When the nerve temperature is decreased, nerve conduction velocity decreases in

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proportion to the degree and duration of the temperature change

• 5 minutes or longer

• The decrease in nerve conduction velocity that occurs with 5 minutes of cooling fullyreverses within 15 minutes in individuals with normal circulation

• Cold can decrease the conduction velocity of both sensory and motor nerve

• A-delta fibers, which are small-diameter, myelinated, pain-transmitting fibers,demonstrate the greatest decrease in conduction velocity in response to cooling

Increased pain threshold

• Application of Cryotherapy can increase the pain threshold and decrease thesensation of pain

• Mechanisms for these effects include

• Counter-irritation via the gate control mechanism and the reduction of

• Muscle spasm,

• Sensory nerve conduction velocity, or

• Post injury edema

Altered muscle strength

• Depending on the duration of treatment icing increases and decreases musclestrength

• Isometric muscle strength has been found to increase directly after the applicationof ice massage for 5 minutes or less

• Mechanism for this response to brief cooling includes facilitation of motor nerveexcitability and an increased psychological motivation

• After cooling for 30 minutes or longer, isometric strength has been found to decreaseinitially and to increase an hour later

• Mechanisms for the reduced strength after prolonged cooling include reduction of bloodflow to the muscles, slowed motor conduction, increased muscle viscosity, and joint orsoft tissue stiffness.

Effects of cold on strength of muscle contraction

Decreased spasticity

• Cryotherapy can temporarily decrease spasticity

• Two mechanisms are proposed to act sequentially to produce this effect:• First, a decrease in gamma motor neuron activity and

• Later, a decrease in afferent spindle and Golgi tendon Organ activity

• After more prolonged cooling, lasting for 10 to 30 minutes, a temporary decrease orelimination of spasticity and clonus and a reduction in resistance to passive motion

• These changes are thought to be caused by decrease in the discharge from the

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afferent spindles and Golgi tendon organs as a result of decreased muscle temperature.

• These later effects generally persist for 1 to 1.5 hours and can therefore be takenadvantage of in treatment by applying Cryotherapy to hypertonic areas for up to 30minutes before other interventions, to reduce spasticity during functional ortherapeutic activities

Facilitation of muscle contraction

• Brief application of Cryotherapy facilitates alpha motor neuron activity to produce acontraction in a muscle that is flaccid due to upper motor neuron dysfunction

Metabolic effects

Decreased metabolic rate

• Cold decreases the rate of all metabolic reactions, including those involved ininflammation and healing

• Cryotherapy is recommended as a treatment for the prevention or reduction of collagendestruction in inflammatory joint diseases such as osteoarthritis and rheumatoidarthritis

TYPES OF COOLING AGENTS

1. Cold packs or ice packs

2. Ice cups for ice massage

3. Controlled cold compression units

4. Vapocoolant sprays or brief icing

5. Frozen towels

6. Ice water immersion

7. Cold whirlpool

8. Contrast bath

USES OF CRYOTHERAPY

• Inflammation control

• Edema control

• Pain control

• Modification of spasticity

• Symptom management in multiple sclerosis

• Facilitation

• Cry kinetics and cryostretch

Inflammation Control

• Decreasing tissue temperature slows the rate of the chemical reactions that occurduring the acute inflammatory response and also reduces the heat, redness, edema,pain, and loss of function associated with this phase of tissue healing

• The decrease in blood flow caused by vasoconstriction and increased blood viscosity, and

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the decrease in capillary permeability associated with Cryotherapy, impede themovement of fluid from the capillaries to the interstitial tissue, thereby controllingbleeding and fluid loss after acute trauma.

• These effects reduce the redness and edema associated with inflammation control pain

by decreasing the activity of the A-delta pain fibers and by gating at the spinal cordlevel

• Controlling the edema and pain associated with inflammation limits the loss of function associated with this phase of tissue healing.

• Cryotherapy after exercise reduce the severity of delayed-onset muscle soreness(DOMS)

• DOMS is thought to be the result of inflammation from muscle and connective tissuedamage caused by exercise

• Cryotherapy can effectively decrease post activity soreness

• When Cryotherapy is applied with the goal of controlling inflammation, the treatment

time is generally limited to 15 minutes or less because longer application has beenassociated with vasodilation and increased circulation

Edema Control

• During acute inflammation, edema is caused by extravasation of fluid in to theinterstitium caused by increased intravascular fluid pressure and increased vascularpermeability

• Cryotherapy reduces the intravascular fluid pressure by reducing blood flow in to thearea via vasoconstriction and increased blood viscosity.

• Cryotherapy also controls increases in capillary permeability by reducing the release of vasoactive substances, such as histamine.

• The formation of edema associated with inflammation will be most effectively controlledif the cryotherapy is applied in conjunction with compression and elevation of theaffected area

• Cryotherapy is not effective in controlling the formation of edema caused byimmobility and poor circulation

• This is best accomplished with compression, elevation, heat, exercise, and massage

Modification of Spasticity

• Cryotherapy can be used to temporarily reduce spasticity in patients with uppermotor neuron dysfunction

•Brief applications of cold, lasting for about 5 minutes, cause an almost immediatedecrease in deep tendon reflexes

• Longer applications, for 10 to 30 minutes, also decrease or eliminate clonus anddecrease the resistance of muscles to passive stretch

• Longer applications of cryotherapy control more of the signs of spasticity cryotherapyshould be applied for up to 30 minutes when this is the treatment goal

• Decrease in spasticity produced by prolonged cooling generally lasts for 1 hour or

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longer after the treatment, which is sufficient to allow for a variety of therapeuticinterventions, including active exercise, stretching, functional activities.

Pain Control

• Decrease in tissue temperature produced by cryotherapy may directly or indirectlyreduce the sensation of pain

• Cryotherapy directly and rapidly modifies the sensation of pain by gating paintransmission by activation of the cutaneous thermal receptors

• Applying cryotherapy for 10 to 15 minutes or longer can control pain for 1 or morehours. This prolonged effect is thought to be the result of blocking nerve conduction bydeep pain-transmitting a-delta fiber

• Reduction of pain by cryotherapy can also interrupt the pain-spasm-pain cycle

Facilitation

• The rapid application of ice as a stimulus to elicit desired motor patterns, known as

quick icing a technique developed by RoodCryokinetics and Cryostretching

• Cryokinetics is a technique that combines the use of cold and exercise

• This technique involves applying a cooling agent to the point of numbness shortly afterany injury to reduce the sensation of pain and thus allow the patient to exercise andwork toward regaining range of motion

• This approach is most commonly used in the rehabilitation of athlete

• Cold is applied first for up to 20 minutes, or until the patient reports numbing of thearea;

• then the patient performs strengthening and stretching exercises for 3 to 5 minutesuntil sensation returns

• The cooling agent is then reapplied until analgesia is regained.• This sequence of cooling, exercise, and recooling is repeated approximately five times

Cryostretch is the application of a cooling agent before stretching. The purpose of thissequence of treatments is to reduce muscle spasm and thus allow greater range-of-motion increases with stretching

CONTRAINDICATIONS AND PRECAUTIONS FOR

CRYOTHERAPY

Cold Hypersensitivity (Cold-induced Urticaria).

This reaction is marked by the transient appearance of smooth, slightly elevated patches,which are redder or more pale than the surrounding skin and are often attended bysevere itching

Cold intoleranceCold intolerance. in the form severe pain, numbness, and color changes in to cold, canoccur in patients with some types of rheumatic diseases

Cryo globulinemia

• Cryoglobulinemia is an uncommon disorder characterized by the aggregation of serumproteins in the distal circulation when the distal extremities are cooled

• These aggregated proteins forms a precipitate or gel that can impair circulation

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Paroxysmal Cold Hemoglobinuria

Paroxysmal cold hemoglobinuria is the release of hemoglobin into the urine from lysedred blood cells in response to local or general exposure to cold

Raynaud's disease or phenomenon

characterized by sudden pallor and cyanosis followed by redness of the skin of the digits

precipitated by cold

Over regenerating peripheral nerves

Cryotherapy should not be applied directly over a regenerating peripheral nerve becauselocal vasoconstriction or altered nerve conduction may delay nerve regeneration.

Over an area with circulatory compromise or peripheral vascular disease

Cryotherapy should not be applied over an area with impaired circular ion because it mayaggravate the condition by causing vasoconstriction and increasing blood viscosity

PRECAUTIONS

Over the superficial main branch of a nerve

• Applying cold directly over the superficial main branch of a nerve, such as theperoneal nerve at the lateral knee or the radial nerve at the postero lateral elbow, maycause a nerve conduction block.

Over an open wound

• Cryotherapy should not be applied directly over any deep open wound because it candelay wound healing by reducing circulation and metabolic rate

Hypertension

• cold can cause transient increases in systolic diastolic blood pressure, patients withhypertention should be carefully monitored during the application of cryotherapy

In patients with poor sensation or poor mentation

• The patient cannot sense or report discomfort and other abnormal responses, theclinician should note for the patient's response directly

Very young and very old patient

• Caution should be used when applying cryotherapy to the very young or the very oldbecause these individuals frequently have impaired thermal and a limited ability tocommunicate.

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Cold Cryotherapy Notes