Cryotherapy (just another fancy name for ice application) is a widely used therapeutic modality for both the treatment of acute soft tissue injures, and during rehabilitation.
The immediate application of ice aims to provide a cold induced analgesic effect, thereby reducing the appreciation of pain.
ice application reduce the tissue temperature, which decreases cell metabolism in the area
surrounding the injury, and decreases the amount of secondary damage in the tissue surronding the injury. animal studies demonstrate a significant decrease in cell metabolism when tissue temperature is lower to 5 degrees.
the main effect of ice is decrease nerve conduction velocity, by reducing pain from surface tissue. this allows your patient to perform their exercises and mobilise the area, which has a secondary effect of reducing swelling.
What is the best way to apply ice?
the different scenarios will help to explain the rationale and are applicable to any sport.
1) Acute setting: Return to play
the athlete has received a trauma to the ankle/ foot complex but there is no significant structural damage. here the aim of the ice application is to provide quick pain relief before the athlete returns to activity. the best modality to use is an ice bag containing crushed ice, as it has been shown to reduce temperature to critical levels required for analgesia within 5 minutes.
you should consider the use of wet-ice application, where ice is applied through a fabric bag, this porous material provides a barrier to stop potential ice burn, whilst the residual water is in contact with the skin. as cryotherapy modalities absorb heat through conduction and evaporation, wet ice exhibits greater thermal conduction than that of its dry ice counterpart.
2) Acute setting :Remove from play
the athlete has received a significant trauma to the ankle and there is significant structural damage and must cease activity. here the ice application aims to provide pain relief, but more importantly compression needs to be applied.
in an effort to reduce the oedema from building up, the compression will shut down the available space for the fluid to accumulate. as a result, wet ice application is no use here as the compression will not be consistent as the water escapes the porous bag. instead, the dry ice
method of crushed ice should be applied in a plastic bag and attached with a compression bandage. the ice is not the most important criteria here, it is the compression.
apply the ice for 10 minutes on, and then remove for 10 minutes, in the rest period, reapply the compression bandage. after the 10 minutes rest, reapply the ice application. continue this cycle off 10 on 10 for as long as possible.
the rationale for 10 minutes on 10 minutes off, not only allows the skin a rest period from constant cold, but more importantly, the modalities ability to absorb heat is at its maximal for at least 10 minutes, before the modality temperature may begin to rise. additionally, at thermal
gradient is created between the skin and the intramuscular tissues, which allows cold to be reached at depth. when the ice is reapplied for a second 10 minutes the tissue temperature at depth has not risen to pre-treatment levels and therefore can reach a lower temperature still.
so, rather than the traditionally 20 minutes continuous, where the modality may start to warm after 15 minutes, here you still receive a combined total of 20 minutes ice application, but the tissue maintained at a lower temperature for over 30 minutes.
3) Rehabilitation:
promote recovery by using cryokinetic protocols (cryokinetics simply means cold and motion). in the instance of an ankle sprain, the athlete immerses their foot into an ice and water mix until their foot becomes numb. the typical sensations you can expect to feel are burning, stinging
and aching. after this, the athlete begins to perform their rehabilitation exercises, so in the early stages simple non-weight bearing range of motion work. continue to perform the exercises until the period of analgesia is diminished (typically 5 minutes), before immersing your foot again to achieve another period of analgesia.
as you progress through the rehabilitation stages, right up to return to activity, you can still use the cryokinetic protocols. so why are we doing this?
the ability of cryotherapy to provide an analgesic effect enables exercises to be performed earlier than would normally be possible. cryokinetics allows the muscles to contract, and therefore they will actively pump the swelling out of the area via the lymphatic drainage system. so by applying the ice application you can perform simple range of motion exercises early than normally would be possible, and thus reducing swelling quicker.
Contraindications and precautions to ice therapy:
Contraindications:
Active deep vein thrombosis or thrombophlebitis
Areas near a chronic wound
Cold hypersensitivity eg Raynaud’s, cryoglobulinema, hemoglobulinemia
Cold urticaria (cold allergy or hypersensitivity)
Impaired circulation
Over regenerating nerves
Tissues affected by tuberculosis
Haemorrhaging tissue
Untreated haemorrhagic disorders Areas with impaired circulation
Precautions:
People with cardiac failure
People with hypertension
Areas of impaired sensation that prevent people form giving accurate and timely feedback
Infected tissues
Damaged or at-risk skin
In summary:
1- Trauma with no significant structural damage, use crushed ice in a damp cotton bag.
2- Trauma with significant structural damage, use crushed ice in aplastic bag with compression wrap applied.
3- Rehabilitation: use mixture of ice and water (1-4 degree)
References:
Cold Modalities With Different Thermodynamic Properties Produce Different Surface and Intramuscular Temperatures
Mark A. Merrick 1, Lisa S. Jutte, Michael E. Smith
The Magnitude of Tissue Cooling During Cryotherapy With Varied Types of Compression
David Tomchuk, MS, LAT, ATC, CSCS,* Mack D. Rubley, PhD, LAT, ATC, CSCS*D,† William R. Holcomb, PhD, LAT, ATC, CSCS*D,† Mark Guadagnoli, PhD,† and Jason M. Tarno, DO‡
Cooling efficiency of 4 common cryotherapeutic agents
Jane Kennet 1, Natalie Hardaker, Sarah Hobbs, James Selfe
Comparison of skin surface temperature during the application of various cryotherapy modalities.
R. Kanlayanaphotporn, P. Janwantanakul
Published 1 July 2005
Medicine
Archives of physical medicine and rehabilitation
Is it possible to achieve optimal levels of tissue cooling in cryotherapy? C. M. Bleakley &J. T. Hopkins
Pages 344-350 | Published online: 19 Jul 2013