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Cold Treatment Therapeutic benefits of cold application post-acute injury, post operative and during rehabilitation are well documented. 1-4 This article is to provide you with sound knowledge of the art of cryotherapy and it’s dangers. Following trauma, hemorrhage and edema at the injury site lead to a pooling of tissue fluids and blood products that increase pain and muscle spasm (protective mechanism). The increased pressure and decreased blood flow to the injury site can lead to hypoxia (deficiency of oxygen). As pain continues the threshold of pain is lowered. These events lead to the cyclical pattern of pain-spasm-hypoxia-pain. For this reason cryotherapy is preferred during acute inflammation to decrease circulation, cellular metabolism, the need for oxygen and the conduction velocity of nerve impulses to break the pain spasm cycle. 4 Pain and muscle spasm are reduced as a result of the cryotherapy’s effect on the nervous system. Cold reduces the rate of firing in nerves to the point that sensory nerve conduction is blocked and thermal anesthesia or numbness is experienced. 1-2 Wide ranges of cryotherapy modalities exist and are relatively inexpensive and easy too implement: -
The advantage of cryotherapy is it decreases pain to allow the patient to receive the benefits of active motion that may otherwise not be tolerated. The muscle pumping action of active motion aids in removal of dead tissues, pain inducing substances and excess fluid lingering at the injury site. 1 Movement however small is better than immobilization. But be aware that ice is an anesthesia to mask pain, you may not realize the damage you are causing when exercising beyond moderate intensity. Application Cryotherapy should be used immediately after sustaining injury (first 24-48hrs). It can also be used in the later stages of injury treatment as a therapeutic modality. 1) A cold pack may be used to cover a joint or muscle. The length of time for which ice should be applied depends to a certain extent on the size of the area and depth of the injured structure, but convention suggests 15 minutes every 1-2 hrs initially. The frequency of application can be gradually reduced over the next 24 hours. 3 It is best to wrap the injury site in a towel first to avoid ice burns. 2) The ice massage may be applied to smaller injury areas. An ice cup may be prepared by, filling a small paper cup with water and freezing it. Tear the upper edge of the cup away and slowly rub ice in small circles over injury site 5-10mins. 3 If injury site is over 10cm use an ice pack. An elastic wrap can decrease swelling yet still expand in cases of extreme swelling. Elevation uses gravity to reduce pooling of fluids and pressure inside the venous and lymphatic vessels to prevent fluid from filtering into surrounding tissue. Precautions You should never exceed the above recommended amount of time for application of ice since this can increase swelling as a result of the blood returning to the area, to warm the tissue because it has been cold for too long. Also monitor the area for itching, sweating or raised bumps with red borders as this may an allergic reaction to the ice. Do not use: - over areas of skin that are in poor condition Over areas of skin that have poor sensation to heat and cold Over areas of the body with known poor circulation In the presence of infection Do not use ice packs on the left shoulder if you have a heart condition Do not use around the front or sides of the neck.
References 1. Knight KL. Cryotherapy in
Sport Injury Management. Champaign, Ill: Human Kinetics; 1995:3-18, 59-71,
77, 107-130, 175-177, 217-232. 4. Anderson MK, Hay SJ, Martin M. Sport Injury Management (2ED) (2000). Lippincott and Williams.
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Heat Treatment Thermotherapy, or heat application, is typically used in the second phase of rehabilitation to increase blood flow and promote healing in the injured area. If used during the acute inflammatory stage, heat application may overwhelm the injured blood and lymphatic vessels, leading to increased haemorrhage and edema. Heat should not be applied in the first 24 hours following acute injury. Applied at the correct time of injury, heat application can increase circulation and cellular metabolism: produce an analgesic or sedative effect: and assist in the resolution of pain and muscle guarding spasms. Vasodilation and increased circulation result in an influx of oxygen and nutrients into the area to promote healing of damaged tissues. Debris and waste products are removed from the injury site. Used prior to stretching exercises, joint mobilisation or active exercise thermotherapy can increase extensibility of connective tissue, (tendons, ligaments and muscles ect.) leading to increased range of motion (ROM). 2 Heat modalities are relatively inexpensive and easy too implement. Superficial thermotherapy · Whirlpools. · Hot tubs and Jacuzzis, · Moist hot packs and · Paraffin wax · Heat packs/ hot water bottle Penetrating thermotherapy · Ultrasound · Diathermy heat Application Thermotherapy can be used when motion is limited by stiffness; it is the preferred modality by many patients during the sub-acute and chronic stages for tissue healing.1) A heat pack/hot water bottle may be used to cover a specific joint or muscle for 15-30 minutes depending on the depth of injury. It can be repeated 2-3 times per day. Cover the area first with a towel the heat pack should be warm not hot (a mild to moderate sensation). Check the area every 5 minutes throughout the treatment for redness or signs of burning. 3 Never lie on top of the pack as this may accelerate the rate of heat transfer leading to burns on sensitive skin. Precautions You should never exceed the recommended time of heat application to avoid over heating and burns. Never use during the first 24 hours of acute injury. Do not use if you have poor circulation, impaired or poor sensation, or over areas of skin that are in poor condition. Avoid heat application is you have a heart condition, hypertension, infection, deep vein thrombosis, diabetes, peripheral vascular disease or dermatitis. Never use over an open wound. Heat treatments should not be administered un attended due to its relaxing effect and chance of superficial burns. Athletes with soft tissue contracture and muscle spasm can be recommended to use 20 min of heat treatment before a workout followed by 20 min of ice application.
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