CRYOTHERAPY 1.pdf

CRYOTHERAPY 1 General Intervention Methods Academic Year 23-24 Degree in Physiotherapy USP-CEU SCHEME DEFINITION MODELS OF HEAT TRANSFER EFFECTS USES 2 COLD OBTAINED WILL DEPEND ON: METHOD USED: Ice bags>ice packs TREATMENT DURATION: Skin vs deeper tissues. INITIAL TEMPERATURE OF THE METHOD USED: th...

CRYOTHERAPY 1 General Intervention Methods Academic Year 23-24 Degree in Physiotherapy USP-CEU SCHEME DEFINITION MODELS OF HEAT TRANSFER EFFECTS USES 2 COLD OBTAINED WILL DEPEND ON: METHOD USED: Ice bags>ice packs TREATMENT DURATION: Skin vs deeper tissues. INITIAL TEMPERATURE OF THE METHOD USED: the greater the difference between object-tissue, the greater. THERMAL CONDUCTIVITY OF THE AREA 3 MODE OF HEAT TRANSFER CONDUCTION: Solid state: Ice packs, ice bags, cold packs, wet cold towels. CONVECTION: Hydrotherapy applications: cold baths and cold showers. EVAPORATION: Vapocoolant spray 4 EFFECTS OF COLD Decreased tissular temperature and tissular metabolism. Decreased blood flow. Decreased edema and swelling. Decreased pain and muscle spasm. (Freire et al. 2016, Hawkins 2016, Hoens 2013) 5 PHYSIOLOGICAL EFFECTS OF COLD HEMODYNAMIC EFFECTS Initial decrease in blood flow. Later increase in blood flow. NEUROMUSCULAR EFFECTS METABOLIC EFFECTS. 6 HEMODYNAMIC EFFECTS OF COLD Immediate constriction of the cutaneous vessels: 20-30 minutes more important where cold is applied. Cold-induced vasodilation (CIVD) or Hunting response: After 20-30 minutes of continuous cold application. Tissue temperature reaches less than 10ºC. Most common in distal extremities. 7 HEMODYNAMICAL EFFECTS OF COLD 8 NEUROMUSCULAR EFFECTS OF COLD Decreased nerve conduction velocity Decreased temporal spasticity Increased pain threshold and decrease pain sensation. Altered muscle strength Facilitation of muscle contraction 9 NEUROMUSCULAR EFFECTS OF COLD Decreased nerve conduction velocity Nerve conduction velocity decreases in proportion to the degree and duration of the temperature change. Cold can decrease the conduction velocity of both sensory and motor nerves. Decreased temporal spasticity: Due to the decrease in gamma motor neuron activity, and the decrease in afferent spindle and Golgi tendon organ activity. 10 NEUROMUSCULAR EFFECTS OF COLD Increased pain threshold and decrease pain sensation due to: A counter irritation via the gate control mechanism Reducing the rate of blood flow in an area, controlling postinjury edema formation. 11 NEUROMUSCULAR EFFECTS OF COLD Altered muscle strength: Isometric muscle strength increase directly after brief cooling (ice massage for 5 minutes or less). After a 30-minute period or longer, isometric muscle strength decreases initially and increase 1 h later due to: slowed motor nerve conduction increased muscle viscosity increased joint or soft tissue stiffness muscles’ blood flow reduction 12 NEUROMUSCULAR EFFECTS OF COLD Facilitation of muscle contraction: A brief application of cryotherapy facilitates alpha motor neuron activity to produce a contraction in a flaccid muscle due to upper neuron dysfunction. A prolonged cooling implies a decrease in gamma motor neuron activity reducing the force of muscle contraction. 13 METABOLIC EFFECTS OF COLD Decreased metabolic rate: Cryotherapy can be used to control acute inflammation but it is not recommended when healing is delayed. The activity of cartilage-degrading enzymes is decreased: cryotherapy indicated in prevention or reduction of collagen destruction in inflammatory joint diseases (rheumatoid arthritis and osteoarthritis). 14 SENSATIONS IN RESPONSE TO CRYOTHERAPY 1. Intense cold (within 3 min of application) 2. Burning/Deep Aching (from 4-7 min of application) 3. Local anaesthesia to analgesia (from 8-15 min of application) 4. Analgesia and numbness (after 15-30 min of application). 15 COLD HYPERSENSITIVITY TEST A massage with the ice cube applied for 3 minutes. After 5 minutes the cutaneous reaction can be seen. If there is an erythema which lasts for 5 minutes before turning normal, the test is negative. If the erythema is replaced by a papula, the test is positive. 16 CRYOTHERAPY USES Inflammation control. Edema control. Pain control. Modification of spasticity 17 INFLAMMATION CONTROL Cryotherapy can be used to control acute inflammation (to control the bleeding and the edema). Once the local temperature returns to normal, the acute inflammation has probably resolved and cryotherapy should be discontinued (to avoid slowing chemical reactions or impairing circulatory during the later stages of healing). The prophylactic use of cryotherapy after exercise reduces the delayedonset muscle soreness (DOMS). 18 INFLAMMATION CONTROL Cryotherapy can be used to control acute inflammation (to control the bleeding and the edema) Cryotherapy must be applied as soon as possible after the trauma (5 minutes) over the injured area to minimize both the extent of soft-tissue damage and the inflammatory response. The sooner the treatment is applied, the greater and more immediate the potential benefit. When cryotherapy is applied with the goal of controlling inflammation, the treatment time is limited to 15 minutes or less, because longer application has been associated with vasodilation and increased circulation. 19 CLINICAL PROBLEM: INFLAMMATION Signs and symtoms: 5 CARDINAL SIGNS Timing: Acute phase (First 72 h after an injury) Clinical Aim: To limit the extent of inflammation Intervention and mechanism of action: Ice: decrease metabolic rate and reduced blood flow: control extent inflammation Contrast baths: effective in distal part of extremities RICE method: most effective in the first 48-72 h after injury. Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. British Journal Sports Medicine 2020, 54:72-73. 20 EVIDENCE FOR INFLAMMATION CONTROL Intermitent compression and continuous ice water for inflammation control both more effective than intermitent cold pack therapy for foot/ankle injuries. After 24 h of treatment swelling was more decreased in the groupo that used intermitent compresion. 21 PEACE & LOVE PROTOCOL Dubois B, Escuelier JF. Soft-tissues injuries simply need PEACE and LOVE. Br J SPorts Med January 2020; 54(2):3-5. CLINICAL PROBLEM: EDEMA Signs and symtoms: No heat nor redness, edema, pitting edema and swelling Timing: 72 h till 7 days Clinical Aim: To control extraarticular swelling and to quickly resolve intraarticular swelling Intervention and mechanism of action: Muscle pump (improve circulation and lymphatic drainage) Active gentle muscle contractions Soft tissue massage Elevation and compression 23 EDEMA CONTROL Cryotherapy can be used to control edema formation especially if edema is associated with acute inflammation: Cryotherapy reduces the intravascular fluid pressure by reducing the blood flow via vasoconstriction and increased blood viscosity. Cryotherapy has the effect to control increases in capillary permeability by reducing the release of VD substances like histamine. Cryotherapy must be applied as soon as possible after the acute trauma to minimize edema formation and with the RICE method. Not effective in case of edema due to immobility or poor circulation. Edema: Decrease plasma oncotic pressue, increase in hydrostatic pressure and increase in capillarity permeabiliy 24 CLINICAL PROBLEM: PAIN Signs and symtoms: PAIN Timing: Acute phase (First 72 h after an injury) Clinical Aim: To control pain Intervention and mechanism of action: Ice Slow nerve conduction More effective and appropiate for acute vs chronic pain. 25 PAIN CONTROL Cryotherapy can control pain: Immediate effect: GATE CONTROL THEORY 10-15 minutes of cold application can control pain for 1 or more hours. Ice massage or vapocoolant spray. Prolonged alleviation of pain: reduced muscle-spasm-pain cycle. Indirectly reducing edema and swelling that causes pain. 26 EVIDENCE FOR PAIN CONTROL Ice massage cools muscle faster than ice pack. Ice pack and cold whirpool for 20 min decreases calf temperature equally but after 20 min only whirpool decreases temperature. Intermitent compression and continuous ice water more effective than intermitent cold pack. (Stockle U et al.1997) Continuous versus intermitent cold water immersion (basketball players recovery: (Sanchez-Ureña B et al. 2017) 12 min versus 4x2 min and 1 out of water 27 MODIFICATION OF SPASTICITY Cryotherapy can be used to reduce spasticity temporarily in patients with upper motor neuron dysfunctions. Brief applications of 5 min cause an immediate decrease in deep tendon reflexes. Longer applications (10-30 min) decrease and eliminate clonus and the decrease of muscles for passive stretch. If the aim is to reduce spasticity longer applications are the best because the cooling effect lasts for 1 hour after the treatment. 28