2022 Cryotherapy

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CRYOTHERAPY LECTURE

Welcome to the presentation on cryotherapy by Dr. Alfred Bracciano and
Dr. Scott McPhee.

Prior to proceeding with the presentation on cryotherapy, you should first
be familiar with the corresponding chapter in the textbook, Physical
Agent Modalities: Theory and Application for the Occupational Therapist
by Dr. Alfred G. Bracciano.

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After completing this lesson, you should be able to:

• List the biophysical and biophysiological changes that occur
during cryotherapy.

• Identify the indications, contraindications, and precautions
for the application of cold agents.

• Demonstrate the clinical reasoning involved in theapplication
of cold agents.

• Identify commonly used types of cold agents.

• And describe the application procedures for each cold
modality.

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Background

• Greek word for cold is cryos
• Application of cold will:

– relieve pain
– decrease inflammation
– reduce swelling

• The process of cooling can:

– exert an effect on tissue from 1-2 cm
– reduce metabolic activity
– decrease nerve conduction velocity
– reduce muscle spasm and guarding

• Cold can be an effective NMS facilitative modality

The term cryotherapy is derived from the Greek word cryos which means
“cold.” The application of cold is a common intervention when treating
acute injuries to relieve pain, decrease inflammation and reduce swelling.

Cold modalities are effective because the process of cooling can exert a
physiological effect
• on tissues to a depth of 1 to 2 centimeters,
• reduce local metabolic activity of underlying tissues,
• slow nerve conduction and,
• by its direct effect on muscle spindle activity, reduce muscle spasm and
guarding.

Cold can also be used effectively in neuromusculoskeletal rehabilitation as
a facilitative modality to induce movement.

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Conduction

• Exchange of thermal energy occurs when
two surfacescome into contact with each
other.

• When a cold physical agent is applied to the skin:

– heat is transferred from patient’s extremity to the cooling
agent

– molecular activity is slowed
– specific physiologic response is achieved

• Cold treatment products include:

– ice packs
– chemical gel packs
– cold packs

Conduction is the exchange of thermal energy that occurs when two
surfaces come into contact with each other.
For example, when a cold physical agent is applied to the skin, heat will be
transferred from the patient’s extremity to the cooling agent and reduce
the temperature of the skin because the molecular activity is slowed and a
specific physiologic response is achieved.

Cold treatment can be applied with commercially available products such
as ice packs, chemical gel packs, and cold packs. These products are
available in the clinic and also over-the-counter.

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Conduction

• Methods of application:

– ice chips
– frozen chunks of ice
– ice slush (1 part alcohol and 2 parts water

mixed in aplastic bag and then frozen)

• Method of application will depend
ondesired therapeutic effect

For home use, cold packs can be made with
1. a bag of ice chips,
2. frozen chunks of ice (typically frozen in 3-5 ounce cups)
3. ice slush composed of 1-part alcohol and 2 parts water mixed in a
plastic bag and then frozen.

When deciding which cold modality to use, the choice will depend on the
desired therapeutic effect since the temperature change of the tissue and
the subsequent biophysical effects of cooling are directly related to

▪ the time of exposure,
▪ the method to cool the tissue, and
▪ the conductivity of the tissue.

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Biophysical Rationale

• Evaporation
• Cold Sprays (vapo-coolant):

– reduce pain and muscle spasms
– use over acupressure or trigger points

and alongreferred pain routes
– spray directly onto the skin in a liquid state
– affect the most superficial depths of skin,

primarily theA nerve fibers
– interrupt the pain signal as described in the

gate control theory

Another way thermal heat is transferred is through evaporation.

For a substance to evaporate, it must absorb energy and change from a
liquid to a gas or vapor like when the human body cools itself through
sweating.

In therapy, cold sprays such as fluori-methane or ethyl chloride have been
used to reduce pain and muscle spasms.
• These sprays can be used over acupressure or trigger points, as well as along
referred pain routes.
• Vapo-coolants are sprayed directly onto the skin in a liquid state that absorb
heat from the skin, and consequently, cool the skin.

However, they can only affect the most superficial depths of the skin and
then primarily the A nerve fibers. This can impact the pain and muscle
spasm responses as described in the gate control theory.

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Biophysiological Response

• Cold material on the skin causes
animmediate hemodynamic
effect:

– constricts cutaneous blood vessels
– activates cold receptors that stimulates smooth

muscles of blood vessel walls
– inhibits production of histamine and

prostaglandins
– increases blood viscosity

When cold material is placed upon the skin, the immediate hemodynamic
effect is a constriction of the cutaneous blood vessels.

There is an activation of the cold receptors, that in turn, stimulate the
smooth muscles of the blood vessel walls.

This cooling process also inhibits the production of histamine and
prostaglandins which triggers the vasodilatation response of blood vessels.

Furthermore, there is an increase of blood viscosity which results in a
resistance to flow.

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Biophysiological Response

• Superficial cold can decrease tissue
temperatureand produce:
– significant analgesic response
– diminish nerve conduction velocity
– decrease edema by reducing lymphatic
and venousdrainage
– reduce muscle spasm/excitability
– diminish muscle spindle depolarization
– lower metabolic activity

Superficial cold can:
• decrease the tissue temperature and produce significant analgesic
response,
• diminish nerve conduction velocity,
• decrease edema by reducing the lymphatic and venous drainage,
• reduce muscle spasm and excitability,
• diminish muscle spindle depolarization, and
• lower the metabolic activity.

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Conductivity

• Physiological response will depend on:

– time of exposure
– type of modality used
– conductivity of the tissue
– affected tissue depth

• Deeper subcutaneous tissue:

– requires longer exposure to cooling agent
– changes influenced by type and depth, but will

depend on thermal conductivity

The amount of time to affect a physiological response is related to
• the time of exposure,
• type of method used,
• thermal conductivity of tissue, and
• the depth of the affected tissue.

The deeper subcutaneous tissue such as muscles and joints will require a
longer exposure time to the cooling agent to cause biophysiological
changes. The type and depth of the tissue will also influence the changes,
but this will depend on the thermal conductivity of the tissue.

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• Thermal conductivity refers to the “efficiency” ofthe
tissue to conduct heat

• Muscle is a good conductor, while fat and adiposeact
as an insulator

• Skin temperature can change very quickly, and
damage to the skin and tissue may occur before
biophysical effects can be achieved

• Obese patients do not have the same biophysical
effect and may require longer exposure time

Thermal conductivity refers to the “efficiency” of the tissue to conduct
heat.

Muscle is a good conductor due to the amount of its water content,
whereas fat and adipose act as an insulator.

Since skin temperature can change very quickly, damage to skin and tissue
may occur before the desired biophysical effects can be achieved.
However, obese patients do not have same biophysical effect and may
require longer exposure time.

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Biophysiological Response

• Hunting response:
– a delayed vasodilation of arterioles following a
period of cooling
– occurs with long, cold applications (usually
exceeding 15 minutes) when tissue
temperatures drop to 50o F (10o C)
– vasodilation of blood cells occurs for 4-6
minutes followed by vasoconstriction for up to
30 minutes
– some believe the redness is actually due to
oxyhemoglobin concentration rather than
hunting response

A delayed vasodilation of arterioles following a period of cooling is referred
to as the “hunting response.”

Basically, vasodilation is a reaction in which blood vessels increase in size. If
a cold technique is applied for long periods of time (exceeding 15 minutes
and the tissue temperatures reach 50oF or 10oC), the body may react by
causing vasodilatation for 4 to 6 minutes.

This, in turn, is followed by vasoconstriction for up to 30 minutes. When this
reaction occurs, it is called the “hunting response.”

The redness that is seen in the body part that is under the cooling modality
may seem to be a sign of vasodilatation.

However, some believe this is actually due to an increase in the
oxyhemoglobin concentration of the blood that is created by the
vasoconstriction response.

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Cold applications should be used judiciously since cold affects the rate of
metabolic reactions involved in the inflammatory and healing process.
Cooling selected tissues can also affect the healing process by delaying the
production of metabolites that are needed for this process.
Furthermore, cooling can interrupt the inflammatory process and either
impede the healing process or enhance it, depending on the condition of
the tissues involved.

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The application of a cryotherapy technique to the
skin will produce three distinct stages of
sensation.

• First, the patient will experience a feeling of
cold against the skin.

• Second, there will be a stinging/burning
sensation that can last several few minutes.

• Third, there will be an aching sensation.
• And finally, there will be a numbness,

followed by pain relief.

Treatment times can vary and range from as little
as 5 minutes to upwards of 15 minutes
depending on the

• area being treated,
• depth of penetration, and
• the cooling method.

Generally, individuals with thicker subcutaneous
tissues will require longer periods of time to
achieve a therapeutic response, whereas
individuals who are thin may require less time.

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Contraindications

• If patient’s condition worsens or does not improve
within 2 or 3 sessions, reconsider treatment approach
and intervention

• Medical conditions:

– impaired circulation
– peripheral vascular diseases
– hypersensitivity to cold
– impaired skin sensation
– open wounds or skin conditions
– infections

• Patients with hypersensitivity to cold may experience a

histamine-like response

The application of cold is generally a safe and effective treatment
intervention.

However, cryotherapy is contraindicated for some conditions, while
caution should be used for others. As with any modality, if the patient’s
condition worsens or does not improve within two or three sessions, the
treatment approach and intervention should be reconsidered.

Cold therapy is contraindicated for any medical condition in which
vasoconstriction will increase the symptoms. Such conditions include
impaired circulation, peripheral vascular diseases, intolerance or
hypersensitivity to cold, impaired skin sensation, open wounds, or skin
conditions (such as psoriasis) and infections.

Some patients with hypersensitivity to cold may experience a histamine-
like response evidenced by skin changes and marked by slightly elevated
patches, redness, or paleness, and may include itching and discomfort.

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Contraindications

• Do not apply cooling agents to patients
whohave been diagnosed with:

– cold urticaria
– cryoglobulinemia
– Raynaud’s disease

• Edema may result due to
increasedpermeability of lymph
vessels

Do not apply cooling agents to patients who have been diagnosed with
• cold urticaria,
• cryoglobulinemia, or
• Raynaud’s disease.

Cryotherapy may also result in edema due to the increased permeability
of the lymph vessels.

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Contraindications
Cold urticaria

Cold urticaria is also called cold hypersensitivity or
cold allergy.

When cold is applied to the skin, a patient may
experience adverse reactions either during or after
treatment.

The more commonly experienced reactions include
gentle to violent local skin reaction (such as wheals
or hive like reaction).

Some patients may develop various systemic reactions such as sneezing,
dysphasia, increased heart rate, decreased blood pressure, and syncope
due to large releases of histamine.

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Cryoglobulinemia

Cryoglobulinemia is a reaction to cold application whereby there is an
abnormal collection of blood proteins that forms a gel in small vessels.

This can result in a disruption of blood flow, cause tissue ischemia, and
even develop into gangrene.

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Raynaud’s Phenomenon

Raynaud’s phenomenon is a connective tissue disease in which blood
vessels are in a constant state of vasoconstriction characterized by pallor,
cyanosis, rubor, numbness or tingling, or burning sensation of the digits.

This reaction can be precipitated by emotional upset, cold, and variations
in temperature that are frequently manifested in young women.

The symptoms are bilateral and symmetrical in individuals with Raynaud’s
disease.

However, for patients with Raynaud’s phenomenon, the response will
generally occur only in the cooled extremity.

Raynaud’s phenomenon and physiological reactions may also be
associated with other syndromes such as carpal tunnel, thoracic outlet or
following traumatic injuries.

Never apply a cooling agent to someone with compromised circulation,
peripheral vascular disease, hypertension, or a past history of frostbite.

Circulatory conditions and impairments are often associated with
peripheral vascular disease, trauma or the healing process and are often
accompanied by edema.

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It is also important to determine the cause of edema and to distinguish
between edema secondary to inflammation rather than due to poor
circulation.

In general, inflammatory conditions causing edema are characterized by
heat or redness to the area, while circulatory disorders are often
distinguished by the coolness and pallor of the skin.

INDICATIONS

Effective in decreasing many effects of acute musculoskeletal trauma,

Cryotherapy can be used therapeutically to treat this partial list of

indications by using cooling as an adjunctive modality:
• During acute/subacute

inflammation
• Acute pain
• Chronic pain
• Acute swelling
• Myofascial trigger points
• Muscle guarding
• Muscle spasm
• Acute muscle strain
• Acute ligament strain
• Acute contusion
• Bursitis
• Tenosynovitis
• Tendonitis
• Delayed onset muscle

soreness

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Most common use of cryotherapy is in the treatment for an acute injury
and during inflammatory process, initiated within 24 – 48 hours following
post injury.

P*R*I*C*E is the standard protocol of positioning, rest, ice, compression,
and elevation, is also effective in decreasing many of the effects of acute
musculoskeletal trauma.

• Position
• Rest
• Ice
• Compression
• Elevation

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Therapeutic Response

When tissue cooling is used as an adjunctive modality, it can contribute
positively to the therapeutic effect by producing

• analgesia,
• reducing edema,
• decreasing muscle spasms, and
• reducing the metabolic activity of the cooled tissues.

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Analgesia

• Application of a cooling agent
may lead tofour stages of
anesthetic response:

– intense cold sensation and reddening of
the skin(hyperemia)

– burning sensation
– deep aching

– analgesia and in 10 – 20 minutes

The intensity and rapidity of analgesia is dependent on the application of
the cooling agent and may lead to four stages of anesthetic response. The
initial stage of cooling is marked by

• intense cold sensation and reddening of the skin.
• followed by a “burning” sensation,
• then a “deep aching” feeling, and
• finally, analgesia will occur in approximately 10 to 20 minutes.

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Analgesia

Cold has a direct effect on the nerves and nerve endings and causes
analgesia through counter irritation (as described in the gate control
theory), and also decreases the metabolic activity within the tissue.

The small, myelinated pain fibers are the first that will be affected by the
reduction in temperature that result in analgesia.

This is due to the decrease in blood flow to the affected area that reduces
the inflammatory process and ultimately curtails the edema formation.

Consequently, this will result in a decrease of pressure on the nerves, and
thereby, decrease the pain.

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Analgesic Advantage

The analgesic advantage is that the patient can become involved in
activities and occupations which previously may have been limited due to
pain.

However, care must be taken to prevent further injuries when increasing
any physical activity since the pain threshold will have changed.

Although the analgesic effect may decrease the need for pain medication,
the therapist must monitor the patient’s activity level to ensure that
further trauma does not occur as a result of over activity.

With a reduction in the pain threshold, a false sense of security could
occur that may possibly lead to aggravating the original condition or even
result in a new injury.

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Nerve Conduction Velocities
With a decrease in temperature, there is a concurrent decrease in nerve
conduction velocities along with a decrease in acetylcholine production.
Individuals with normal circulation will generally recover within 15
minutes from a decrease in nerve conduction after 5 minutes of cooling.
However, after 20 minutes of cooling, reversing the effect on delayed nerve
conduction velocity will take approximately 30 minutes or longer.
This should be noted during
treatment and when
assessments are being
conducted.

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• Following an acute musculoskeletal
trauma, acooling modality should be:

– physical agent of choice for first 24 – 48 hours
– applied to injured area for a period of 20 minutes

per ½half hour to 30 minutes per 2 hours for first
6 – 24 hoursafter trauma
•

blood vessels due to sympathetic reflex
response that affects smooth muscles of blood
vessels

A major concern following an injury or disease is the onset of edema.

When confronted with edema following an acute musculoskeletal trauma,
a cooling modality should be the physical agent of choice for the first 24 to
48 hours.

The cooling modality should be applied to the injured area for a period of
20 minutes per half hour to 30 minutes per 2 hours for the first 6 to 24
hours after the trauma.

This modality will produce a vasoconstriction of blood vessels due to a
sympathetic reflex response that affects the smooth muscles of the blood
vessels.

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Edema Control

• Cooling reduces edema when combined
with compression since vasoconstriction
of the arterioles and venules occurs
within 15 minutes after application

• Post-operative patients should receive less
intense cooling agent 3 – 4 times daily for
20 – 30 minutes to decrease thermal
damage to surgical repair

Cooling is also very effective in reducing edema when combined with
compression since vasoconstriction of the arterioles and venules will occur
within 15 minutes after applying the agent.

For post-operative patients, a less intense cooling agent should be applied
3 to 4 times daily for 20 to30 minutes and combined with compression
and elevation to decrease the thermal damage of a surgical repair.

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Edema Control
Cryotherapy can be an effective intervention to control the development
of edema when it is associated with acute inflammation.

Cryotherapy decreases the intravascular fluid pressure by decreasing
blood flow into the affected area and by increasing the blood viscosity.

Cryotherapy also affects capillary permeability by decreasing
histochemical release during the inflammatory phase of healing.

Ice packs are also helpful when applied up to 30 minutes because they can
conform to body contours and can produce comfortable and safe pain
relief.

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Muscle Spasm Control

A muscle spasm can have a detrimental effect to occupational
performance because of the pain and limited range of motion.

When a cooling agent is applied over a muscle spasm, the cold
temperature will affect the muscle spindle mechanism as well as the
sensory wrappings of the spindle mechanism, and thereby, decrease the
spasm.

Consequently, the patient will gain a
better range of motion and should be
able to resume routine functional
activities.

Cryotherapy can also be used to
temporarily decrease spasticity in
patients with upper motor neuron
lesions.

Applications of cold for 10 to 30
minutes may decrease clonus and
resistance to passive stretch, but longer applications over 30 minutes will
be more effective in decreasing spasticity.

When combined with static positional stretch or contract-relax
techniques, cold packs or ice massages are effective counter measures for
muscle spasms.

Generally, 10 to 20 minutes of cooling should be enough time to decrease
muscle spasms in most individuals unless they are obese.

Spasticity reduction following prolonged cooling will generally last up to
one hour, and occupational activities can be resumed thereafter since

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cooling the tissue will affect both the spastic muscle and the normal
muscle tone.

It is important to note that if a hand or forearm
segment is cooled to less than 80.6°F, grip
strength and the ability for sustained muscle
contraction will be reduced.

Most patients will also experience a decrease in
the ability to perform fine motor activities
following the cold applications.

Consequently, it may be problematic and even
frustrating for the patients who engage in
occupations that require fine motor dexterity.

Furthermore, measuring grip or pinch strength following superficial
cooling of the tissue may hamper accurate results.

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Most commonly used cold agents include cold packs, ice massages, cold
and ice water immersion baths, cool whirlpools, ice towels, and
vapocoolant sprays.

Each agent can effectively meet the physiological and therapeutic
objectives associated with the relief of pain and the decrease in the
inflammatory process.

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Cold Packs

Cold packs are an effective and inexpensive method for administering cold
to an area.

Typical applications of cold compression include:
• commercial cold packs (including gel packs)
• homemade alcohol pack
• crushed ice in a plastic bag
• Frozen bag of peas.

An advantage to using cold packs
is the ability of the pack to
conform to the extremity or area
which is being treated.

Use of cold packs is also
advantageous because the
therapist can target large or
multiple areas for treatment and
combine elevation and icing to
facilitate edema reduction.

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When a cold pack is used to
alleviate musculoskeletal injuries, it
should ideally cover the entire
muscle from origin to insertion,
though this is not always possible.

The cold pack can be applied
directly to the area, or it may be
wrapped in a wet or dry towel or a
pillowcase and then applied to the
area.

An insulating material should
always be used when the ice pack is
placed over a bony prominence.

If a distal extremity such as a hand, wrist, or elbow is the targeted tissue,
the extremity can be covered with an Ace wrap, compression wrap,
stocking, or tubigrip to maintain and hold the position of the cold pack on
the area being treated.

Cold packs may be left on the treated area for 10 to 20 minutes but should
be closely monitored to prevent tissue damage from rapid or prolonged
cooling.

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Ice Massage

Ice massage is a frequently applied physical agent that is mostly used to
anesthetize a relatively small area or to disrupt the pain cycle of a trigger
point.

Ice massage is very effective when the area of treatment is superficial,
localized, and relatively small. However, when the ice cup begins to melt
during the application, the patient should be positioned comfortably, and
the treated area should be draped with a towel to absorb the melting
water.

As with any cryotherapy application, the size of the area to be treated and
the amount of adipose (or fat tissue) need to be considered before
applying the intervention.

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Ice massages can be performed with ice cups or Popsicles made by
freezing water in small cups or Styrofoam cups. It is recommended that a
tongue depressor be placed in the cup before freezing it so that
afterwards the stick can be used as a handle when the cup is removed.

When applying ice massages, patients should be informed about the
sensory stages of cooling they may encounter such as feelings of

• cold,
• burning,
• aching, and
• numbness.

They should be repeatedly asked which sensory stage they are
experiencing.

Ice massages are performed by slowly rubbing or moving the modality in
small rhythmical circles while maintaining direct contact with the skin at all
times.

When patients report numbness or lost feeling of touch, it is generally safe
to continue the circular motions for approximately one more minute.

However, ice messages should rarely exceed 7 minutes because frostbite
and tissue damage may occur due to the intensity of the cold.

It should also be noted that patients will usually experience numbness
within a time frame of 3 to 10 minutes.

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Cold Water Immersion

Cold or ice water immersion baths are most often used for edema
reduction.

When immersion baths are used in conjunction with string wrapping or
compression wrapping, they are therapeutic for treating digital and hand
injuries, and may also be effective in decreasing edema in the extremity.

The treatment application will depend on the therapeutic goal and the
amount of adipose tissue present in the extremity.

The water temperature, though, should be between 35 and 75 degrees
Fahrenheit and the treatment duration should be between 15 and 20
minutes.

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It should also be noted that when colder water is used, the amount of
treatment time required to achieve the therapeutic goals will be shorter.

The main advantage of using cold water immersion is that the cooling
agent will come into contact with the entire tissue area when the
extremity is completely immersed in water.

Cold water immersion can also be effective for wound debridement after
the tissue has reached its analgesic effect.

However, the main disadvantage of cold-water immersion is that it will
place the extremity in a dependent position.

Therefore, to avoid additional edema in the extremity, the patient should
participate in fisting or moving of the digits and periodic elevation of the
extremity to facilitate venous return.

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Ice Towels

Ice towels are another cost-effective way for applying a cooling agent at
home.

An ice towel may contain ice chips or ice shavings, or it may be dipped in
ice water and subsequently wrung out before it is draped around the
targeted area.

However, the cooling ability of an ice towel will diminish quickly, and
therefore, must be changed approximately every 5-6 minutes.

A primary disadvantage of this method is that it may be uncomfortable
and messy because of the melting, runny water.

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Cold Compression Units

Cold compression units are refrigerated units that circulate cooled water
over the targeted area.

• They consist of a sleeve which is placed around the individual’s
extremity and cold air and water are pumped through the sleeve.

• Because the cooled medium circulates through a sleeve or garment
which surrounds the targeted area, this method of cryotherapy is
effective in the reduction of edema.

These units are also used immediately
after surgery to control postoperative
inflammation in which the sleeve is placed
on the patient in the recovery room and a
cold compression unit is given to the
patient for application at home.

The temperature on some cold
compression units can be adjusted that is
a useful feature when treating
musculoskeletal injuries.
For this type of modality, most patients
can tolerate treatments at 50 degrees
Fahrenheit for 15 to 20 minutes.
Adjustable cold compression units are
also effective in controlling post-surgical
pain and swelling and can facilitate in
regaining the range of motion.
Another advantage of this technology is
that it allows the application of cold and
compression simultaneously that can be
easily and effectively controlled by the
therapist or physician.

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Precautions

Cold is an effective intervention in
which the physiological effects can
last several hours. However, there
are certain precautions a therapist
should follow when using a cold
agent.

• Since rewarming the
extremity tissues can take
approximately 20 minutes,
care should be taken when
applying a cold agent and the skin should be closely monitored to
ensure there are no adverse reactions.

• When the patient reports numbness, which indicates analgesia, the
patient’s protective sensation is no longer functional and the
individual should be cautioned against overuse or reinjury of the
affected extremity.

• Some patients may also be sensitive to cold and experience such
side effects as itching, hives, sweating, wheal areas with reddened
borders, and blanched centers.

• If the cryotherapy is too severe in the distal extremities such as the
hands, edema may result because of the increased permeability of
the lymph vessels.

• Also, cold gel packs should not be placed directly on the skin and
never longer than 20 minutes.

If cold is applied too long, it can cause tissue damage and even tissue
death due to prolonged vasoconstriction, ischemia, and thromboses in the
smaller blood vessels when the temperature drops to 15 degrees
Centigrade (or 59 degrees Fahrenheit).

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Also, freezing of the tissue or frostbite can occur when the skin
temperature drops between -4 and -10 degrees Centigrade (or between
25 and 14 degrees Fahrenheit).

Furthermore, improper application or prolonged exposure to cold may
cause temporary or permanent nerve damage.

For any application, the total length of time should always be less than 45
minutes and the tissue temperatures should not drop below 15 degrees
Centigrade (or 59 degrees Fahrenheit).

What is the The Celsius and
difference
between Celsius centigrade temperature
and Centigrade? scales are the same
scales, where 0o is the
freezing point of water
and 100o is the boiling
point.

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Patient Monitoring

Though cold can be easily and safely applied, patients should always be
monitored regularly and closely for reactions to the treatment.

Never apply any form of cryotherapy for longer than 45 minutes and look
for any changes in the patients’ skin color and response.

Also, review if there have been any changes or revisions to the treatment
plan and goals.

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Documentation

At a minimum, document:
• the treatment parameters,
• duration,
• site of the application,
• position of the patient,
• the type and method of cooling agent that was used.

Furthermore, documentation must always comply with institutional, local,
state, and federal regulations and requirements.

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Things to Remember

Therapists should always:

• monitor the patient’s blood pressure since cold can cause
temporary increase in systolic and diastolic blood pressure;

• avoid using cryotherapy in patients who have impaired
circulation or are hypersensitivity to cold;

• avoid application directly over any wounds after 2 to 3 weeks of
post injury; and

• avoid prolonged placement over superficial nerves.

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Case Study 1

History and Assessment

The patient is a 36 year old male clerk who has been referred for
“evaluation and treatment” with a diagnosis of medial epicondylitis. The
patient complains of moderate “throbbing pain” and “constant aching”
which is most noticeable during frequent activity. The pain is over his left
medial epicondyle which prevents him from participating in racquetball
and “working out.” The pain initially occurred approximately 2 weeks after
a racquetball tournament at the gym. Consequently, his physician started
a course of NSAIDs which “took the edge off.” During the evaluation, the
patient stated he had similar symptoms in the past, particularly after
heavy workouts or extensive use of the upper extremities, but they always
seemed to resolve themselves. The physical examination revealed point
tenderness with associated swelling at the left medial epicondyle and pain
with resisted wrist extension, including after the grip and pinch tests.
However, sensation, range of motion, and strength were all within normal
limits.

The patient manifests the impairments of pain, point tenderness, and
swelling of the left elbow.

The pain also increases with joint loading and resistance.

He has an inability to participate in normal exercise activities and routines
and has noticed an increase of the symptomology while performing the
occupational components of his assigned tasks at work.

Therapeutic Goals

• The proposed therapeutic goals for the patient include resolving the
inflammation, decreasing the pain, and decreasing the swelling.

• The long-term goals include establishing measures to prevent future
reoccurrences so that he can be pain free to comfortably perform his
employment tasks and be competitive during leisure activities.

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Determination ofAppropriateness

Cryotherapy can be used prophylactically to prevent post exercise
inflammation and soreness and is also an indicated treatment for
inflammation and pain.

Furthermore, cryotherapy can be appropriate over other treatments
indicated for these applications since it is quick, easy, and an inexpensive
approach that can be applied at home.

Finally, cryotherapy can be used in conjunction with other physical
technologies such as ultrasound, iontophoresis, or electrical stimulation as
well as activity and ergonomic modifications, manual therapy techniques,
and/or exercises.

However, due to the superficial nature of the nerves, the patient should
be monitored for nerve conduction blockage that is indicated by tingling
or numbness in the forearm.

Proposed Treatment Plan

• An ice massage, ice pack, or cold pack should be applied to the area
of the medial epicondyle.

• An ice massage is the most advantageous modality because of the
ability to visualize the area being treated, and monitor signs and
symptoms during treatment.

• The application should be 5 to 10 minutes long depending on the
patient’s subjective reporting. However, it should be immediately
discontinued if neurological signs extend into the hand.

• The application should continue until the signs and symptoms of
inflammation are resolved, and then discontinued to prevent
decrease in the rate of tissue healing.

• Following the resolution of inflammation, other technologies such as
iontophoresis, ultrasound, or electrical stimulation may be added.

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• Also, after performing activities that exacerbated the condition or
caused the initial symptoms (i.e., racquetball, weightlifting,
occupational job requirements), recommend the prophylactic use of
ice.

This ends the module on Cryotherapy.