Basic Information for Physiotherapy Students

1. Anwesh Pradhan
MPT (Neurological & Psychosomatic
Disorders(
Asst. Prof. NIHS, Kolkata
Cons. Mobility Physiotherapy, Midnapore

2.  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°.

3.  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.

4. Physiotherapeutic Uses of the
Circulatory Effect:
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.

5.  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.

6.  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.
 In practice, motor nerve paralysis is never
produced by ice.

7.  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

8.  Reduces pain.
 Reduces spasticity.
 Reduces muscle spasm.
 Reduces swelling.
 Promote repair of the damaged tissues.
 Provide excitatory stimulus to inhibited
muscles.

9.  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.

10.  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.

11.  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.

12.  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.

13.  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.

14.  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
 Excitatory cold ( quick ice)
 Ice spray
 Cold gel
 Etc…

15.  Cardiac Conditions
 Psychological:
 Peripheral Nerve Injuries
 Vasospastic Disease
 Peripheral Vascular Disease
 Cold Sensitivity

16.  Acute injuries are those which result from
traumatic incidents (a fall, twisting movement
or direct blow for example) and are immediately
painful.
 When an acute injury first occurs, bleeding,
inflammation, swelling and pain must all be
controlled. Ice should be applied as soon as
possible in order to cool the tissues, reduce
their metabolic rate and nerve conduction
velocity and cause vasoconstriction of the
surrounding blood vessels.

17.  Ice should remain in contact for up to 20 minutes at
a time (dependant on the size of the area being
treated and the depth of the injured structure) and
be re-applied regularly, every 2-3 hours.
 Following approximately the first 3-5 days of an
acute injury, once bleeding has stopped and there
are no signs of inflammation, you may wish to
alternate cold and heat treatments. That is apply
cold for 10 minutes, followed immediately by 10
minutes of heat. Doing this causes massive
increases in blood flow to the area as the
vasoconstriction caused by cooling reverses when
heat is applied, resulting in an influx of blood to the
damaged tissues. Ensure all bleeding has stopped
before applying this technique. Blood is vitally
important in providing all of the energy and nutrients
that the body needs for repair.

18.  Chronic injuries usually do not present with a
sudden onset. They tend to gradually build up
over a period of days, weeks or longer and are
often caused by overuse or biomechanical
abnormality. A chronic injury can also be
caused by an acute injury which fails to heal
due to a lack of, or inappropriate treatment.

19.  Heat therapy should be applied for 15-20 minutes
in the form of hot water bottles, a warm damp
towel, heat rub or commercially available heat
pads. If using something such as a hot water bottle,
ensure a suitable layer of protection is placed over
the skin to prevent burns.
 In general heat should be used to treat chronic
injuries, to help relax tight, aching muscles and
joints, increase elasticity of ligaments and tendons
and increase the blood flow to the area. Heat
therapy can also be used prior to exercise in
chronic injuries to warm the muscles and increase
flexibility.
 The only time ice should be used on chronic
injuries is after exercise, to reduce any residual
swelling.

22. Precautions:-
o Over superficial main branch of a nerve
o Over an open wound - delays healing
o Hypertension - can cause transient increases in
systolic or diastolic BP
o Patients with poor sensation
o Very young or very old
o impaired temperature regulation,
o ability to communicate

23. Adverse Effects
o Tissue Death
o Frost Bite
o Nerve damage
o Freezing of tissues

24.  An ice pack is any type of container which
holds crushed or chipped ice. It can be a
plastic bag, towel or specially designed
ice bag.. These tend to cool the
underlying tissues more efficiently than
commercial chemical or frozen gel packs
and remain cold for a longer period. They
can be held in place if required by an
elastic bandage or specialist wrap.

25.  These commercially available packs contain a
gelatinous substance which is kept frozen in a
freezer until required. Better examples contain
some form of anti-freeze which prevents the
gel from freezing into a rigid position, allowing
the pack to be molded to the shape of the
body part. These are good for use in a clinic
setting as they are re useable and not as
messy as ice packs. However when taken out
of the freezer they immediately begin to thaw
and so are not suitable for use on the field of
play. They must also be applied to the skin
through a towel or cloth to prevent frostbite.

26.  These are one use cold packs where
compressing and rupturing a central
pouch, contained with the pack,
releases a second chemical which
causes a reaction which lowers the
temperature of the pack. These packs
do not lower in temperature enough to
significantly reduce tissue
temperature. They are however
convenient for emergency use. Any
leak from the pack would cause a
chemical burn.

28.  A terry towel is put into a mixture of
flaked ice & water & then wrung out,
much of the clipped ice will be found to
adhere to the cloth.
 This can be placed over a large area to
give immediate surface cooling.
 The ice towel will need to be replaced
by another one after 2 – 3 min.
 It is particularly useful method for the
treatment of muscles & allows
movement or exercise to be performed
while cold therapy is being applied.

29.  Technique:
 Towels thoroughly soaked in water & ice
mixture
 Towel wrung out & applied to part;
Procedure repeated every few min
 Duration: 10-15 min
 Advantages:
 Equipment required is available almost
anywhere
 Disadvantages:
 Therapist must keep changing towels

31.  An ice bath can easily be made by half-filling a
large container/tub with cold water and ice.
The size of the container and depth of the
water required depends on the body part to be
treated. This is the best method of cooling
awkward, bony areas, such as the foot, ankle,
hand and elbow. Immediately following injury,
submerging the injured body part may not be
as beneficial as using a cold pack and
compression wrap, as there is no compression
(RICE principle). Wrapping the ankle prior to
submersion will also prevent maximal cooling
by insulating the body part.

33.  Ice can be used to massage the affected area.
Usually cubes are frozen with some form of
handle (a simple lollypop stick will suffice) in
order to protect the hands of the masseur. This
method is most suitable for injured muscles
and larger areas. The ice should be stroked up
and down the injured muscle. The
disadvantage of this type of massage is that
the application is phasic, that it the ice is in
contact with each area only briefly. Following
this it is exposed to air temperature which
reduces the efficacy of tissue cooling.
However, numbing of the area is quite efficient
due to the movement of the ice stimulating
mechanoreceptors in the muscles.

34.  Technique:
 Sensation = cold, burning, aching, numbness
 Part being Rx’d may become pale &
eventually red
 Ice should be applied in circular, smooth,
rhythmical strokes
 Duration: 3-10 min
 Advantages
 Numbs skin easily in short time
 Ice colder than chemical cold packs
 Ice readily available
 Disadvantages: ice may cause frostbite

36. Adding a plate weight will increase
numbness.

37.  These sprays evaporate quickly
when they come into contact with
the skin. This removes heat from
the skin at the same time. They
result in only a very superficial
cooling effect and therefore are
limited in their efficiency.

39.  The Cryocuff is a machine which consists of a gallon
tank of ice water and a nylon sleeve, into which you
place the injured part. The ice water flows through
the cuff to cool the body part. The tank must be
raised to allow more water to flow into the cuff and
increase the pressure. In this way compression is
also applied to the injury. To cool the water sitting in
the cuff, the tank is lowered to allow it to flow back
into the tank where it mixes again with the ice water.
The tank can then be raised again to fill the cuff. The
Cryocuff allows a good degree of cooling and
compression, is relatively portable and re useable.
Different shaped and sizes of cuff can also be
purchased to allow use for all body parts.

41.  When a skin injury occurs, the RICE
procedure should be followed. In order to
also prevent infection the ice you apply can
be combined with an antiseptic. In a
plastic cup, mix together distilled or boiled
water with 10% povidone-iodine and 2%
lidocaine. Secure a lollypop stick or similar
in the centre with tape and freeze. When
required, roll the ice back and forwards
over the skin for about 10 minutes. and
then treat as normal.

43. First the body part is cooled for up to 20
minutes in which time it should become
numb.
Following this two sets of 65 second
stretches are applied with a 20 second rest
between sets. Each period of 65 seconds
consists mainly of static stretching, with
three 5 second isometric contractions
interspersed throughout the stretch. There
should not be any pain throughout the
procedure.

44.  Ice reduces muscle spasm
 Static stretches overcome the stretch reflex to
reduce muscle spasm
 Muscle relaxation is often greater following a
contraction than before the contraction
 These three components together are more
effective than any individual method

45.  Cryokinetics basically allows exercise which is
pain-free, relatively soon after the injury. The
anaesthesia (numbness) arising from ice
application does not remove pain sensing
mechanisms, it only removes the current pain
(from tissue damage). Due to this, if active
exercises are too vigorous pain will still occur.
 Cold should be applied for a maximum of
twenty minutes which should be sufficient to
produce the numbed response which is
required. The process can be repeated for 5
minutes to 're-numb' the area if necessary.

46.  The exercises performed during
cryokinetics are active (the patient
performs them independantly) and should
be gradually increased in intensity
providing they remain pain free.
 The key to the success of cryokinetics
appears to be progressing as quickly as
possible from one exercise to the other.
Unlike conventional rehabilitation
programs where a certain number of reps
must be completed, if the athlete can
perform the exercise, smoothy and pain
free then they can progress.

47.  Exercise increases blood flow to the injured
area, vital in healing (after bleeding has
stopped)
 Exercise re-establishes neuromuscular
function
 Exercise is possible much earlier than normal
 Muscular atrophy is not allowed time to set in
 Swelling in reduced dramatically through the
combination of cooling and exercise

48. Sources:
 Foster & Palastanga,Clyton’s Eelectrotherapy, 9th
Edition, 2000
 Low & Reed, Electrotherapy Explained, 3rd
Edition, 2000
 Compiled information from various websites
 http://emedicine.medscape.com/article/1125851-overview
 http://www.medicinenet.com/cryotherapy/article.htm
 http://www.uscryotherapy.com/
 https://www.nlm.nih.gov/medlineplus/ency/article/007506.htm
 http://www.webmd.com/cancer/cervical-cancer/cryotherapy-for-abnormal-
cervical-cell-changes
 http://www.cryohealthcare.com/cryotherapy-faqs/
 http://www.cryohealthcare.com/about-cryotherapy/
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC522152/
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3956737/
 http://www.jospt.org/doi/abs/10.2519/jospt.1983.5.2.66#.VfarCtKqqko