Cryotherapy Practices and Guidelines Quiz

Cryotherapy

• Cryotherapy is the use of cold to treat injuries.
• Lecture objectives include understanding basic physical principles of cryotherapy, biophysical principles of tissue cooling, indications, contraindications, and precautions for cold therapy, different methods of providing cold therapy, and assessing treatment outcomes.

Clinical Scenario

• A 17-year-old female soccer player twisted her ankle during a game due to plantar flexion and inversion of her right ankle.
• The injury occurred yesterday, and the ankle is edematous (swollen) and warm to the touch around the lateral malleolus.
• Questions to consider: Which structures are likely involved? Should hot or cold therapy be used, and why? What specific treatment modalities would be appropriate, and why?

Cryotherapy Agents

• Cryotherapy agents are used to cool tissues.

Cooling

• Cooling involves transferring thermal energy. Heat naturally moves from a warmer object to a cooler one.
• Modes of energy transfer include conduction, convection, and evaporation.

Conduction

• Conduction is the transfer of heat by direct interaction of molecules.
• Examples include cold packs.
• Factors affecting conduction include area, thermal conductivity of the cooling agent, temperature difference, time of exposure, and thickness of the tissue.

Convection

• Convection is heat abstraction by direct contact between the skin and moving fluid particles like a cold whirlpool.
• Convection is faster than conduction.
• This is mainly used on distal extremities.

Evaporation

• Evaporation is the process where heat (energy) is absorbed and transforms a liquid into a vapor.
• This method is used in vapocoolant sprays or instant ice devices.

Inflammatory Response Phase

• Signs and symptoms include redness, swelling, tenderness, increased temperature, and loss of function.
• Cellular responses include leukocytes and phagocytic cells.
• Chemical mediators include histamine, leukotrienes, and cytokines.
• Vascular reactions include initial vasoconstriction followed by vasodilation.

Chronic Inflammation

• Acute inflammatory response may be insufficient to eliminate the injuring agent.
• Neutrophils are replaced by macrophages, lymphocytes, fibroblasts, and plasma cells.

Fibroblastic-Repair Phase

• Signs and symptoms may include mild tenderness or pain with movement.
• Revascularization involves the regrowth of blood vessels, increased blood flow, and delivery of nutrients to the area.
• Scar formation begins with the formation of granulation tissue, which includes fibroblasts, collagen, and capillaries.

Maturation-Remodeling

• Collagen fibers realign or remodel.
• There is continuous breakdown and synthesis of collagen which results in increased tensile strength of the scar matrix.
• Fibers realign to optimize efficiency.

Biophysical Principles of Tissue Cooling

• Cold reduces blood flow and prevents the excessive release of chemical mediators, which can lead to bleeding.
• It also reduces metabolism and vasoactive agents thereby decreasing inflammation.
• It also raises pain threshold.
• Hemodynamic effects of cold include reflex vasoconstriction, reduced blood flow, and increased blood viscosity.

Effect on Local Blood Flow

• Cold can decrease blood viscosity and decrease smooth muscle tone.

Biophysical Principles of Tissue Cooling - Continued

• Cold is mostly used for post-traumatic edema and inflammation that occurs 24-48 hours after injury.
• This is also used to treat local edema, inflammation, and reduce local metabolism, decrease secondary hypoxic tissue injury, and decrease accumulation of leukocytes.

Effect on Skin

• The analgesic effect of cold reduces sensitivity to pain in superficial sensory receptors.
• 50% reduction in receptor sensitivity at 27° C (80.6° F)
• Complete nerve block at 8-10° C (46.4–50° F)
• No sensitivity at 5° C (41° F).
• Different stages of cold application might cause different sensations (cold, burning, aching, and numbness).

Biophysical Principles of Tissue Cooling - Muscle Performance

• Short-term cold application has little to no effect, but prolonged cold application results in decreased strength, proprioception, and agility.

Biophysical Principles of Tissue Cooling - Peripheral Nerves

• Cold decreases the temperature of nerve tissue, leading to decreased sensory and motor conduction velocity.
• Syanptic transmission is reduced, increasing pain threshold.
• Significant prolonged cooling can obstruct nerve conduction.

Biophysical Principles of Tissue Cooling - Neuromuscular Effects

• Cold application can decrease spasticity.
• Decreased muscle spasticity helps reduce gamma-moto neuron activity by stimulating cutaneous afferents.

Clinical Indications for Cold Therapy

• Goals include limiting edema formation, reducing pain, facilitating muscle relaxation, and limiting secondary hypoxic tissue injury.

Clinical Indications for Cold Therapy

• Cold therapy is common for acute musculoskeletal trauma (e.g., PRICE method, over casts and bandages).

Guidelines for Cryotherapy

• Factors to consider include accessibility, body part, compression, elevation, previous medical history (PMH), time since injury, and hypersensitivity.
• The procedure should be adjusted to avoid excess stress at the injury site.
• The duration and intensity must be adjusted to avoid negative effects due to time spent.
• Cold can cause temporary numbness, redness, aching, and burning sensation.

Contraindications for Cryotherapy

• Cold hypersensitivity, cryoglobulinemia, hemoglobulinemia, Raynaud's phenomenon, paroxysmal cold hemoglobinuria, deep vein thrombosis (DVT), anterior neck carotid sinus, hemorrhagic conditions, impaired circulation, and areas of nerve regeneration are contraindications for cold therapy.

Contraindications for Cryotherapy (Continued)

• Chronic wounds, hypertension (particularly with systemic cold), infection (if cold is applied over an infected site), tuberculosis, and impaired cognition or communication.

Precautions for Cryotherapy

• Precautions for cryotherapy include hypertension, impaired sensation, damaged or at-risk skin, thermoregulatory disorders, over superficial nerves, open wounds, and very young or old patients.

No Contraindications/Precautions

• Tissues over active epiphysis
• Intact skin overlying implants containing metal, plastic, or cement
• Skin overlying electronic devices
• Low back and abdomen of pregnant women
• Recently radiated tissues
• Reproductive organs
• Areas affected by skin diseases
• Chest, heart, and head
• Inflamed tissues from recent injury

Methods of Providing Cryotherapy

• Common methods include cold packs, frozen peas, ice massage, vapocoolant sprays, manual/electric cold compression units, cold baths, and cold gels.

Methods of Providing Cryotherapy - Ice Massage

• Ice massage involves rubbing ice over a small surface area of the body in overlapping circular motions.
• This is typically done for small body areas, trigger points, muscle bellies, etc.

Methods of Providing Cryotherapy - Vapocoolant Spray

• Vapocoolant spray is applied in sweeps across the skin.
• A notable effect is in reducing motor neuron activity and allowing better stretch or trigger point release.

Methods of Providing Cryotherapy - Ice/Cold Bath

• Ice/cold baths are typically used for distal extremities.
• Water temperature ranges from 50°F to 64.4°F (10°C to 18°C).

Methods of Providing Cryotherapy - Manual and Electric Cold Compression Units

• Manual cold compression involves circulating cold water through a cuff applied over an extremity.
• Cold compression units use electric pumps to regulate cold water circulation.
• Water temperature and compression can be adjusted.

Cryotherapy in Tissue Healing

• Cryotherapy is common during the initial stages of inflammatory response.
• It is effective in reducing edema and speeding healing.
• There is no scientific evidence that cryotherapy aids healing beyond the inflammatory phase.

Cryotherapy in Pain Management

• Cryotherapy can reduce blood flow and prevent the excessive release of chemical mediators to decrease pain.
• It also increases pain threshold and inhibits nociceptors to reduce muscle spasms.

Clinical Controversies

• Controversies include the optimal timing (hours/days) and duration (minutes) of cryotherapy after injury or exercise.
• The benefit of using cryotherapy after heat/stretch therapy is also a noted controversy.
• Also elevation vs combined technique comparison with cold and compression.

Whole Body Cryotherapy

• Whole body cryotherapy involves exposure to extremely low temperatures (-110 to -250 degrees Celsius) in a specialized chamber for 2-3 minutes.
• Recent studies have failed to show a conclusive positive effect of whole body cryotherapy.

Clinical Scenario (2)

• A 17-year-old female soccer player twisted her ankle while playing, resulting in a plantar flexion and inversion injury to her right ankle.
• The ankle is edematous and warm, especially around the lateral malleolus, which happened yesterday.
• She is unable to play for a few days.

Clinical Decision Making

• Consider whether there is a dysfunction, limitation, or problem that may be improved with cryotherapy.
• Determine if the patient is appropriate for cryotherapy.
• Identify specific goals to achieve with cryotherapy use.
• Choose the appropriate cryotherapy method.
• Establish appropriate parameters for the specific method.

Summary

• Tissues can be cooled via conduction, convection, or evaporation.
• Cryotherapy affects various tissues.
• Choose a cooling agent, utilizing clinical decision-making practices.
• Crucial considerations include indications, past medical history, area to be treated, contraindications, precautions, and patient preference.
• Assess outcomes and document them appropriately.

Top Takeaways

• General points related to the discussed topic of cryotherapy, likely a summary of the entire presentation.

Test your knowledge on cryotherapy techniques, duration, and safety measures with this quiz. Explore the recommendations for cold baths, compression methods, and the effects of temperature on treatment outcomes. This quiz also covers key studies and their implications in clinical practice.