304Lecture: cryotherapy

  1. what is the temperature range for cyrotherapy modalities:
    32-65 degrees F

    • 55 for ice bath
    • 32 for ice bags
  2. list the 3 therapeutic goals of cryotherapy:
    • reduce inflammation and edeam: vasoconstriction
    • reduce spasticity: slow nerve conduction
    • facilitate movement: decreased pain = more movement, (not used often, ice before training)
  3. list the 3 effects of COLD:
    • hemodynamic
    • neuromuscular
    • metabolic
  4. list the 2 hemodynamic effects of COLD:
    • initial decrease in blood flow
    • possible later increase in blood flow
  5. list the 5 neuromuscular effects of COLD:
    • decrease in nerve conduction velocity
    • increase pain threshold
    • altered muscle strength
    • decrease spasticity
    • facilitate muscle contraction
  6. list the metabolic effects of COLD:
    decrease in metabolic rate: secondary injury= less hypoxia
  7. list the 4 hemodynamic physiological effects of cryotherapy:
    • activation of cutaneous cold receptor stimulates smooth muscle contraction
    • decrease of mediators (histamine and prostaglandins)
    • reflex activation of adrenergic neurons: release of nor-epinephrine (a vasoconstrictor)
    • increased blood viscosity: increase resistance to flow
    • thickness; not permeable to tissues, gets to target, not interstitial spaces
    • reduce potential for hemorrhages
  8. the physiological effects of hemodynamics, vasoconstriction should last how long:
    • vasoconstriction persists as long as application is limited to 15-20 minutes
    • research has shown increased vasoconstriction with 2 repetitions of 10 minutes of ice vs. 2 minutes of continuous ice
    • if ice is on longer than 20 minutes... vasodilation occurs
    • - no longer stimulating
    • -protection mechanism: to rewarm the body
    • -called: "hunting response"
  9. describe the cold induced vasodilation theory:
    • after 15-30 minutes of cryotherapy, the body adapts to the cold and there is a vasodilation: increase in blood flow
    • research shows that this may not occur or if so, the results are negligible
  10. what is the conclusion of the hemodynamic effects of cryotherapy:
    • cryotherapy does cause vasoconstriction
    • reduces blood flow to the area
    • realistically only effects ongoing hemorrhage not the initial hemorrhage
  11. list the 2 methods by which neuromuscular physiology of cryotherapy decreases spastiticy:
    • decreased gamma motor neuron
    • decreased muscle spindle (muscle contraction) and GTO (elicits muscle relaxation)
  12. how does neuromuscular physiology of cryotherapy increase pain threshold:
    bigger stimulus to elicit pain when structure is cold
  13. how does the neuromuscular physiology of cryotherapy decrease nerve conduction velocity:
    • small diameter, myelinated fibers : A delta's (rid of sharp pain quickly)
    • 5 minutes cooled = 15 minutes of decreased NCV
    • 20 minutes cooling ~ 30 minutes of decreased NCV
  14. how does the neuromuscular physiology of cryotherapy alter muscle strength:
    • brief cooling (5 mins or less)=increased isometric strength
    • prolonged cooling = decreased in strength followed by increase in 2-3 hrs
  15. what are the 4 physiological metabolic effects of cryotherapy:
    • decreased metabolic rate
    • the need for O2 is less by the cells
    • able to survive hypoxic environment due to injury
    • less cells die due to secondary hypoxic injury
    • *best reduced when tx'd within 30 minutes*
  16. what is the temperature that decreased activity of cartilage degrading enzymes ceases at:
    30 Celsius, 86 F
  17. will decreasing metabolism delay healing?
    • icing for too long... longer return to play?? NO
    • will not cease inflammation
    • can't "over" ice
  18. list the 4 clinical applications by which cryotherapy decreases (acute) inflammation:
    • (..by slowing metabolism)
    • decrease heat (temperature): directly via conduction
    • decreases edema (on going swelling)
    • decreased pain-gate: decrease A delta activity (NCV)
    • decrease O2 demand: secondary tissue injury
  19. how do you judge if cryotherapy is the appropriate modality:
    • 5 cardinal signs (swelling, heat, redness, LOF, pain)
    • time injury happened
    • acuity of the injury
    • 2 HR DOMS
    • Pain resistance sequence
  20. describe 4 the clinical applications of cryotherapy for edema control - associated with acute injury:
    • vasoconstriction: decreases intravascular hydrostatic fluid pressure
    • increased blood viscosity
    • decreases vascular permeability through decrease in vasoactive mediators
    • utilize PRICE principle
    • *decrease in blood flow does NOT decrease blood O2 concentration
  21. describe the 4 clinical applications of cryotherapy for pain control (direct and indirect mechanisms):
    • gate control theory
    • NCV of A Deltas
    • lowered pain for 1-2 hours probably due to residual temp. decrease
    • pain spasm pain cycle
  22. describe the 3 clinical applications of cryotherapy for spasticity:
    • decrease afferent, spindle and GTO activity
    • raises activation threshold of the muscle spindle rendering it less excitable
    • 10-30 minute application lasts up to 1 hour
  23. list 7 contraindications for cryotherapy:
    • cold hypersensitivity (cold induced urticaria)
    • cold intolerance
    • sensory deficits : inability to feel
    • cryoglobulenemia or hemoglobinuria: collection of proteins that turn to gel like substance impairing circulation.  RBC released to urine (renal failure)
    • raynaud's
    • PVD (peripheral vascular disease) or circulatory dysfxn (advanced diabetes)
  24. the allergic rxn to cold tx in the form of hives is called:
    cold induced urticaria
  25. the rxn to cold tx that results in the fingers becoming white due to lack of blood flow, then blue as the vessels dilate to keep blood in tissues, then finally red as blood flow returns is called:
    • Raynaud's phenomenon
    • the disease happens in the same extremity that is tx'd
    • the phenomenon happens in the extremity opposite of the tx'd extremity
  26. list 4 precautions to using cryotherapy:
    • superficial main branch of a nerve: ulnar nerve, peroneal nerve (can produce dropfoot for 48 hrs)
    • over open or infected wound: impedes metabolism, so slows wound healing
    • poor sensation or mentation: not able to tell if its too cold
    • tx'ing large areas in those with....
    • -cardiac conditions (vasoconstricts vessel, increased BP)
    • -respiratory conditions: decreased oxygenated blood
    • -hypertension
  27. a cold injury caused by too long of tx time, too cold of temp., chemical cold packs, or vascular insufficiency is called:

    • skin looks white and waxy, very painfull
    • -redness (erythema) is normal after tx
  28. at what subcutaneous temperature can frostbite occur:
    below 55 F, possible tissue damage

    it is unlikely for frostbite to occur when using ice where water is present - if used for proper time and no cold rxn exist

  29. list 7 indications for cryotherapy:
    • acute injury of inflammation
    • acute or chronic pain
    • small, superficial 1st degree burns
    • postsurgical pain and edema
    • in conjunction with rehabilitation exercises (cryokinetics)
    • spasticity accompanying central nervous system disorders
    • acute or chronic muscle spasm
  30. list 4 sensations in response to cold:
    • intense cold
    • burning
    • aching
    • analgesia (inability to feel pain) and numbness
  31. list 7 factors influencing depth, magnitude, and duration of cold tx:

    • tx. temperature
    • specific heat (ability to transfer heat): air vs. water
    • instulating medium (towels, clothing, barriers, ect.)
    • tx duration
    • area of skin tx'd
    • use of a compression wrap (serran wrap, more intense)
    • post-tx activity (rest one hr. untill tissues re-warm)
  32. list 5 factors that influence depth, magnitude, and duration of cold tx:
    • subcutaneous adipose tissue: (check body fat - calipers) insulator, protects
    • -20mm or less = 25 mins
    • -20-30 mm = 40 mins
    • -30-40 mm = 60 mins
    • depth of target tissue: patella vs. deep hamstring
    • vascualrity of target tissues: decreased blood; frostbite risk
    • cell metabolism
    • sympathetic nervous system  (maintains local temperature)
  33. what is the neuormuscular activity at a skin temp of 79 F:
    • muscle spindle activity decreases
    • cramping
  34. what is the neuromuscluar activity at a skin temp of 75 F:
    • motor NCV decreases
    • cramping, spasm
  35. what is the neuromuscular activity at a skin temp of 68 F:
    • ACH NTM decreases
    • decreases pain transmission
  36. what is the neuromuscular activity at a skin temp of 60 F:
    rewarming begings
  37. what is the neuormuscular activity at a skin temp of 58 F:
    maximum analgesia
  38. what is the neuromuscular activity at a skin temp of 55 F:
    risk of tissue damages increases
  39. is a disadvantage of ice immersion:
    • limb is in a gravity dependent position
    • holds swelling in/down
  40. describe the purposed mechanism of contrast baths:
    • pumping actions of vessels
    • vasoconstriction then vasodilation would pump blood
  41. list the 3 reasons why the whirlpool baths needs to be cleaned often with disinfectant:
    • open wounds: cleaned after each pt.
    • commercial cleaner  or hot water/bleach
    • keep stainless steel clean (prevent corrosion/rust)
  42. list 5 whirlpool precautions:
    • need to have GFI's (ground fault interrupter)
    • athletes/patients do not turn machine on/off
    • keep cords off the floor
    • keep floor clean (dry)
    • don not run turbine dry
  43. using cold in conjunction with movement is called:

    • used in ROM exercises to limit pain associated with them
    • be cautions that there isn't too much masking of pain and you are causing further damage to the tissue
  44. cold spray used to decrease skin temp. and pain prior to passive stretch is called:

    passive stretch helps break the pain-spasm-pain cycle (work trigger points)

    causes a quick temp drop in skin by quickly evaporating
  45. what are the indications for cryostretch:
    • muscle spasm
    • trigger points
    • decrease ROM
  46. which is a more dangerous form of cryostretrch vapo coolant:

    fluoromethane or ethyl chloride:
    ethyl chloride
  47. what are the precautions for cryostretch:
    • allergy to spray
    • open wounds
    • protection of eyes
  48. a cooler of ice water, a nylon sleeve for body part, a hose connected to the cooler, and the cooler raised about the sleeve allowing water to flow into the sleeve and provide compression is called:
  49. how much pressure does the cryo- cuff apply:
    30-40 mmHg
  50. a useful cryo-compressive modalitiy that uses a sleeve to cover the extremity and fills with cold fluid and air that is pumped in by the machine is called:
    game ready

    very useful for inflammation control and reducing edema
  51. the depth of penetration of cryotherapy is:
    5 cm

    advantage over heat: penetration gets deeper
  52. how long is the duration of the effects of cryotherapy:

    slow metabolism, prevents 2ndary hypoxic death
  53. blood flow for cryotherapy is:

    increased /decreased
  54. rate of cell metabolism for cryotherapy is:

    increased /decreased
  55. oxygen consumption for cryotherapy is:

    increased /decreased
  56. cell wastes for cryotherapy is:

    increased /decreased
  57. fluid viscosity for cryotherapy is:

    increased /decreased
  58. what are the 4 therapeutic goals of thermotherapy (superficial heat):
    • increase tissue extensibility
    • increase circulation
    • accelerate cell metabolism
    • reduce pain similar to ice pack, gate theory of pain control
  59. list the modes of heat transfer for the following thermotherapy modalities:

    hot pack:
    • hot pack:  conduction
    • WP: conduction + convection
    • fluidotherapy: convection
    • paraffin: conduction
    • infrared: heat source, light bulb
  60. the hemodynamic effects of thermotherapy physiology is:

    • increased blood flow at the level of tissue heating
    • -appropriate modality for targeted tissue
    • whole body heating can cause systemic vasodilation
  61. list the 3 mechanisms for hemodynamic effects of thermotherapy physiology:
    • direct reflex (vessels vasodialate): through the release of nitrous oxide
    • indirect reflex (via spinal cord)
    • chemical mediators
  62. list the 2 chemical mediators of inflammation that vasodilate for thermotherapy physiology:
    • local release of histamine and prostaglandins
    • increases permability
  63. list 3 neuromuscular effects of thermotherapy physiology:
    • increase nerve conduction velocity: propagate signal faster
    • increased pain threshold: raise threshold, able to withstand more pain, more relaxed
    • changes in muscle strength
  64. list things of neuromuscular effects of thermotherapy physiology that increases NCV:
    • increased nerve conduction and decreased latency in both sensory and motor nerves
    • shortens duration of sodium channels opening
    • -demyelinated nerves vulnerable
  65. nerve conduction velocity is also shown to decrease firing rate yielding relaxation in muscle spasm, list the 3 neuromuscular effects:
    • decrease firing rate in Type II muscle spindle and gamma efferants
    • increase firing rate to Type I fibers from GTO
    • thus reducing muscle contraction
  66. list 2 things of neuromuscular effects that increase pain threshold:
    • direct reduction in pain through gate theory
    • indirect pain relief from vasodilation leading to decreased tissue ischemia and muscle spasm reduction
    • GTO's more relaxed
  67. list 2 things of neuromuscular effects that effects muscle strength:
    • initial reduction in strength and endurance secondary to decreased alpha motor neuron activity
    • subsequent increase in strength secondary to reduction in pain
  68. at what temperature does metabolic activity increase:
    102-109 F or 39-43 C
  69. at what temperature does metabolic activity decrease:
    50 C or 122 F
  70. what are the metabolic effects of thermotherapy physiology:
    • increased metabolic and enzymatic rxn
    • increases O2 uptake and potential healing
    • potential negative event through increase collagenase in RA (rheumatoid arthritis)
  71. list 4 things of thermotherapy physiology that increases collagen extensibility:
    • facilitates plastic deformation (cross bridging)
    • greater increase in length with less force
    • decreased risk of tissue tearing
    • maximum increase in length at 104-113 F for 5-10 minutes
  72. the clinical applications of thermotherapy for accelerated healing are: (2)
    • increased circulation
    • increased metabolic rate: increased enzymatic activity, increased availability of O2
  73. the clinical applications of thermotherapy for increased joint mobility, ROM, and decreased joint stiffness are: (3)
    • increased soft tissue extensibility
    • maximum increase in length at 104-113 F
    • stretch during, immediately after : effects of heat only lasts a few minutes
  74. therapeutic goals and TTR (tissue temperature rise)

    classification: mild
    temp increase:
    • temp. increase: 1 C (1.8F)
    • effects: mild inflammatory, increase metabolic rate
  75. therapeutic goals and TTR (tissue temperature rise)

    classification: moderate
    temp. increase:
    • temp increase: 2-3 C (3.6-5.4 F)
    • effects: Decrease spasm, decrease pain, increase in BF, decrease chronic inflammation
  76. therapeutic goals and TTR (tissue temperature rise)

    classification: vigorous
    temp. increase:
    • temp. increase: 3-4 C (5.4-9 F)
    • effects: tissue extensibility
  77. 20-25 min MHP tx will have a TTR (tissue temperature raise) of:
    .5 C at 2.5 cm
  78. list 7 contraindications of thermotherapy:
    • acute injury or inflammation
    • recent/potential hemorrhage
    • thrombophlebitis/DVT
    • impaired sensation/mentation
    • malignancy
    • muscle contusion (myositis ossificiations)
    • IR irradiation of the eyes
  79. list 8 precautions for thermotherapy:
    • pregnancy
    • impaired circulation
    • poor thermal regulation: diabetes, peripheral vascular disease
    • edema: pulmonary, CHF= don't increase circulation; if injury edema maybe ok to increase blood flow for nutrients
    • cardiac insufficiency (local heating)
    • metal: high specific heat, tissue burn
    • over open wound: active bleeding, or infection
    • recent counterritant use: icy hot, bengay.. intensifies
  80. what can cause a burn from thermotherapy:
    • insufficient insulation (6-8 layers)
    • increase pressure (bony prominence)
    • jewelry
    • PTA or aide
  81. what is the temp of the hydrocollator:
    160-170 F
  82. the modality that has low specific heat so the higher temp. can be tolerated better that if it were the same water temp. is called:

    how long is the tx time:
    • paraffin bath
    • tx time: 15-20
  83. which of the  following has modalities has the greatest risk of frostbite:

    C. resuable cold pack
  84. which of the following is a contraindication of the use of a paraffin bath:

    A. skin conditions
  85. which of the following modalities uses convection as the method of heat transfer:

    A. whirlpool
  86. which of the following is not a local effect of cold application:

    C. decreased viscosity of fluids in the area
  87. which of the following modalities has the greatest depth of penetration into the tissues:

    A. ice bag
  88. heat application by itself (i.e. without stretching exercise) is sufficient to enlongate collagen rich tissues:

    a. true
    b. false
    b. false
  89. which of the following is not a local effect of heat application:

    C. increased muscle tone
  90. a ____ degree F drop in skin temp is needed to reduce the sensitivity of muscle spindles:

    C. 9
  91. as the size (area) of the body exposed to cold immersion increases, the temperature of the immersion should:

    a. increase
    b. decrease
    a. increase
  92. the primary reason for the use of cold during the immediate tx of an injury is:

    D. decrease cell metabolims
  93. the "hunting response" has been demostrated to occur in all body parts during cold application:

    a. true
    b. false
    b. false
  94. mosit heat packs are stored in water having a temperature range b/w ___ and ___ F:

    B. 160/170
  95. the thermal effects obtained from a moist heat pack occur up to up ___ cm beneath the skin:

    B. 3

    • 2 cm: superficical
    • 2-5 cm: deep heating
  96. raynaud's phenomenon is a common contraindication to the use of cold and is characterized by:

    D. altering bouts of pallor and cyanosis
  97. following a 20 minute ice immersion and a short rewarming period, there __ a decreased joint porprioceptive ability:

    a. is
    b. is not
    b. is not
  98. which of the following is not a systemic effect to cold exposure:

    A. increased HR
  99. if the goal of your tx is to produce long-lasting cold within the quad. muscle prior to exercise (in the subacute or chronic stage of injury), which one of the following modalities would be most appropriate:

    A. ice bag
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304Lecture: cryotherapy