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Cryotherapy & Thermotherapy. Chapter 4 Therapeutic Modalities. Physiology Basics. Vasodilation Increased size of vascular structures Means more oxygen to the tissue Vasoconstriction Decreased size of vascular structures Useful for preserving compromised/injured cells/tissue.

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cryotherapy thermotherapy

Cryotherapy & Thermotherapy

Chapter 4

Therapeutic Modalities

physiology basics
Physiology Basics
  • Vasodilation
    • Increased size of vascular structures
    • Means more oxygen to the tissue
  • Vasoconstriction
    • Decreased size of vascular structures
    • Useful for preserving compromised/injured cells/tissue
physiology basics1
Physiology Basics
  • Analgesia
    • Diminished/reduced sensation
  • Metabolic rate
    • Activity level of cells
    • Reducing MR can preserve cells damaged by injury
  • Inflammation
    • Series of events that hinder optimal function
  • Alter cell metabolism
  • Each 1.8°F (1°C) change in tissue temp. results in a 13%  or  in the tissue’s metabolic rate.
  • Energy absorbed by one tissue later can’t be transmitted to deeper layers.
    • Law of Grotthus-Draper
      • The more energy absorbed by superficial tissues  the amount absorbed by deeper tissue.
5 mechanisms of energy heat transfer in the body added or removed
5 Mechanisms of Energy (Heat) Transfer in the Body: Added or Removed
  • Conduction – transfer of heat through the direct contact between a hotter and a cooler area (2 objects touching each other)
    • Ice Massage, Hydrocollator Pack, Ice Pack
  • Convection – transfer of heat by the movement a medium (air, liquid) between regions of unequal temperature
    • Whirlpool
  • Conversion – energy is changed from one form to another; does not relate to superficial heat or cold
    • Electrical energy into heat, Acoustical energy into heat
    • Ultrasound, Diathermy
mechanisms of energy
Mechanisms of Energy
  • Radiation – emitted from surfaces with temperatures above absolute 0° (all atomic & molecular motion ceases)
    • Transfer of energy without the use of a medium
    • Body, Sun, Infrared lamp, LASER, Ultraviolet light
  • Evaporation – change from liquid state to gaseous state requiring thermal energy be removed from the body
    • Vapocoolant Spray
cryotherapy cold therapy
Cryotherapy – Cold Therapy
  • Cold modalities range in temp. between 32°F-65°F
  • Heat is removed from the body & absorbed by the cold modality
  • Tissue temperature is LOWERED
  • To obtain therapeutic benefits, the skin temp. must be lowered to approx. 57°F.
  • Cold therapy applied is thought to activate a mechanism used to conserve heat in the body’s core
    • This mechanism triggers a series of metabolic & vascular events that produce the beneficial effects of cryotherapy.
  • Can be used during all stages of healing
  • Normal skin temp. is approx. 91°F
    • The deeper the tissue in the body, the higher the temp.
  • Skin is cooler than adipose which is cooler than muscular tissue.
  • Thermoreceptors in skin are responsive to heat or cold (more to cold than heat).
sensations with cold application
Sensations with Cold Application
  • Cold
  • Burning
  • Aching
  • Analgesia (absence of pain)
    •  of n. conduction velocity &  threshold are required to fire the nerve(s).
cryotherapy indications
Cryotherapy Indications
  • Acute injury or inflammation
  • Pain
  • Muscle spasm, acute or chronic
  • Restoration of ROM
  • Small, superficial, 1st degree burns
  • Post-surgical pain & edema
  • Neuralgia
  • Post-exercise
cryotherapy contraindications
Cryotherapy Contraindications
  • Situations where the body is unable to cope with temp. change because of allergy, hypersensitivity, or circulatory insufficiency
  • Cardiac or respiratory involvement
  • Uncovered open wounds
  • Circulatory insufficiency
  • Cold allergy
  • Anesthetic skin
  • Advanced diabetes
  • Raynaud’s phenomenon or other Peripheral Vascular Disease
  • Lupus
local effects of cryotherapy
Local Effects of Cryotherapy
  •  cell metabolism rate – PRIMARY BENEFIT
    •  need for oxygen
  • Lowers tissue temperature
  • Vasoconstriction
  •  production of cellular wastes
  • Prevents or limits swelling
  •  in pain by  pain threshold
  •  in acute & chronic muscle spasm
  • Limits area of original injury

Deeper tissues cool more slowly & to a lesser extent than skin

    • Muscle tissue requires longer to cool than bony areas
    • Deeper tissue temps. have been proven to drop for several minutes following the removal of an ice pack
    • Research has shown that deeper tissues remaining at rest will be cooled for 2 hr or more after a 20- to 30- min. ice pack application
  • The cold modality will continue to remove body heat until temps. are (=).
  • Take into consideration the amount of pain that occurs during exercise after cold has been applied
  • Be careful when applying an elastic wrap over a cold pack over superficial nerves (Nerve Palsy)
  • Uticaria – hives
cellular response
Cellular Response
  •  cellular metabolic rate
    • During a 20-min. treatment, cell metabolism  19%
  • With  b. flow, there is less metabolic activity & O2 demand on the cells
  •  need for O2
    • Reduces number of cells killed by lack of O2
    • Reduces secondary hypoxic injury damage
    • Reduces amount of chemical mediators released in area
  • Slows nerve conduction
vascular responses
Vascular Responses
  • Vasoconstriction occurs due to stimulation of n. receptors
    • Viscosity of blood & tissue fluids 
    • Resistance to b. flow 
    • Soft tissue  of 26% & skeletal b. flow  of 19% with 20-min. ice pack in injured ankles
  • Amount of b. flow is still under debate
    • Most studies indicate that b. flow 
  • Because of effects associated with rubbing the skin, IM may  b. flow, at least to the skin
tissue temperature changes
Tissue Temperature Changes
  • 57°F skin temp. – optimal decrease in local blood flow
  • 58°F skin temp. – analgesia occurs
  • Temp. within the joint decreases proportionally to temp. of skin overlying a joint decreases
  • Temp. changes most rapidly in skin & synovium
muscle spasm
Muscle Spasm
  • Cold therapy affects pain threshold
    •  nerve conduction velocity by slowing communication at the synapse
    •  pain by reducing the threshold of afferent n. endings.
    •  sensitivity of m. spindles
      • May inhibit the stretch reflex mechanism reducing m. spasm & breaking pain-spasm cycle
  • Changes in cellular function & blood dynamics serve to control effects of acute inflammation.
  • Cold suppresses the inflammatory response by:
    •  the release of inflammatory mediators (histamine, prostaglandin)
    •  prostaglandin synthesis
    •  capillary permeability
    •  leukocyte/endothelial interaction
    •  creatine-kinase activity
pain control
Pain Control
  • Cold therapy acts as a counterirritant
  • Cold application affects pain perception & transmission by:
    • Interrupting pain transmission (stimulates large-diameter A-beta n. fibers)
    • Decreasing n. conduction velocity
    • Reducing m. spasm
    • Reducing or limiting edema
systemic effects of cold exposure
Systemic Effects of Cold Exposure
  • If circulating blood temp.  0.2°F, then the hypothalamus (body’s thermoregulatory center) kicks in
  • General vasoconstriction in response to cooling of the posterior hypothalamus
  • Decreased respiratory & heart rates
    • Heart rate  (wants to localize the cold area)
  • Shivering & increased muscle tone
    • If heart rate  too much where the core temp. reaches hypothermia
application of cryotherapy
Application of Cryotherapy
  • Ice Massage:Should not be applied during acute inflammatory stage as it’s not compatible with compression
    • 5-15 mins. – reduces pain, desensitizes trigger points
    • Vigorous Ice Massage
  • Ice Pack: type of ice – cubed, flaked
  • Commercial Cold Packs: chemical, reusable (Gel)
    • Be aware of frostbite; use insulating layer in between
  • Cryo-cuff/Polar Care:provide approx. 40 mm Hg
  • Cold Water Immersion:
    • Ice bucket: 40 °-50°F
    • Whirlpool: 50 °-60°F
  • Vapocoolant Spray:superficial, rapid cooling through evaporation; virtually no temperature change below epidermis; will numb area briefly (trigger points)
  • Intermittent Compression:Segmental compression with cold
  • Duration usually15-30 mins. Don’t apply for more than 60 minutes!
    • Depends on skinfold thickness
  • Ice with compression – affects deeper tissues
    • Compression encourages  lymphatic drainage
      • Circumferential: compression around entire area (ace wrap)
      • Collateral: compression on both sides (aircast, gelcast)
      • Focal: direct pressure to soft tissue surrounded by bony structure (horseshoe)
  • Cooling of tissue: rapid at first, then slows, then levels off
  • Skin reactions:
    • Hyperemia, pallor
cryokinetics for sub acute injury stage
Cryokinetics for Sub-Acute Injury Stage
  • Alternating cold therapy with exercise
  • Use good judgment! Do not cause further harm!
  • Place cryotherapy to body part for approx. 20 min. (analgesia feeling)
  • Remove cryotherapy & begin active exercise
  • Place cryotherapy back on body part once feeling/pain returns
  • Repeat
hunting response
Hunting Response
  • 1930’s ; Lewis performed skin studies with temperature change during cold treatments.
    • When the fingers were immersed in cold water, alternating periods of cooling & warming were seen in the skin.
    • Thoughts were that intermittent cold-induced vasodilation (CIVD) lasting 4-6 min. after approximately 30 min. of cryotherapy application (p. 109)
    • Stated that it prevented local tissue injury
  • Today’s researchers state that CIVD does not occur during standard cryotherapy sessions.
cryotherapy ice
Cryotherapy (Ice)


  • Ice massage
    • 7-10 minutes
    • Excellent for muscle spasm and deep soreness
cryotherapy ice1
Cryotherapy (Ice)


  • Ice bags, ice towels, or cold packs
    • 15-20 minutes (no longer than 30)
    • If using packs, be sure to avoid direct contact to protect skin!
  • Cold whirlpool / ice immersion
    • 5-15 minutes, 55-65 degrees
    • Duration and temperature depends on surface area immersed