Cold Applications
(Cryotherapy)

Alternative names: Cryotherapy, cold therapy.

Both heat and cold modalities can be used effectively in various clinical conditions.  Therapeutic cold has the primary effect of cooling tissue.  Ice is the most widely used and efficient form of cryotherapy in medicine tody.

Cold application is a simple and inexpensive therapy which has been accepted for decades as an effective nonpharmacologic intervention for pain management.  It increases the pain threshold, decreases the inflammatory reaction and spasm.

Cold is commonly used in the treatment of acute soft tissue injuries and has been shown to reduce pain effectively in the post-operative period after orthopedic surgery procedures.

That said, the evidence base to support the common practice of superficial cold is limited and there is a need for future higher-quality randomized controlled trials.

Function; Why it is Recommended

The most common methods of cold application include cold packs, cold immersion, ice massage, and cooling during exercise (cryokinetics).  Spray and stretch is an application of cryotherapy with a vapocoolant spray, which then is followed by stretching of the involved muscles.  This technique sometimes is used in the management of myofascial pain syndromes, as described by Travell and Simons.

Ice therapy for injuries initially constricts local blood vessels and decreases tissue temperature.  This constriction decreases blood flow and cell metabolism, which can limit hemorrhage and cell death in an acute traumatic injury.  After approximately 20 minutes of ice, blood vessels in the injured area dilate (open) slowly, increasing the tissue temperature, an effect which is termed "reactive vasodilation."  A study found that, despite the reactive vasodilation, there was a significant sustained reduction in local blood volume after ice was applied. [Journal of Orthopedic Sports Physical Therapy, Jul/Aug, 1994]

The most useful local therapeutic cold applications include management of edema, muscle spasm, bleeding, and traumatic pain.  The vasoconstriction effect of therapeutic cold is beneficial for reducing posttraumatic swelling and pain or for reducing hemorrhage into soft tissues.

Depending upon the application method and duration, the basic physiologic effects include the following:

• Decreased local metabolism
• Vasoconstriction
• Reactive hyperemia
• Reduced swelling/edema
• Decreased hemorrhage
• Reduced muscle efficiency
• Analgesia secondary to impaired neuromuscular transmission.

Pain reduction associated with application of cold relaxes muscle spasm and minimizes upper motor neuron spasticity.  The most common indications and uses for local application of therapeutic cold modalities include the following:

• To decrease swelling/edema following trauma (cooling in water at 8°C for 30 minutes decreases edema)
• To treat burns
• To inhibit spasticity (in spasticity, the muscle must be cooled; this process takes 10 minutes in thin patients and up to 60 minutes in more obese persons)
• To reduce muscle spasms
• To reduce acute inflammatory reaction
• To reduce pain
• To reduce limb metabolism (prior to amputation)
• To produce reactive hyperemia
• To facilitate muscular contraction for various forms of neurogenic weakness and for muscle re-education
• To treat restricted knee flexion due to traumatic lower extremity fractures: This improves the condition to a greater degree than superficial heat application, even if either is used in combination with passive stretching using mechanical traction.

Ice is one of the simplest, safest, and most effective self care techniques for injury, pain, or discomfort in muscles and joints.  Ice will decrease muscle spasms, pain, and inflammation to bone and soft tissue.  You can use ice initially at the site of discomfort, pain, or injury.  You can also apply ice in later stages for rehabilitation of injuries or chronic (long-term) problems.

During an initial injury, tissue damage can cause uncontrolled swelling.  This swelling can increase the damage of the initial injury and delay the healing time.  If you use ice immediately, you will reduce the amount of swelling.  Ice decreases all of these: swelling, tissue damage, blood clot formation, inflammation, muscle spasms, and pain.  At the same time, the ice enhances the flow of nutrients into the area, aids in the removal of metabolites (waste products), increases strength, and promotes healing.  This "ice effect" is not related to age, sex, or circumference of the injured area.

Instructions

Immediate application of ice or cold packs for superficial burns and burns of less than 20% total body surface area decreases pain, edema, erythema, and blistering.  For optimal results in cases of trauma, cold should be applied before significant edema and hemorrhage occur.

Therapeutic cold is applied for 5-20 minutes, followed by a rest period of 30 minutes.  For treatment of acute sprains/strains and postoperative care, application of cold is recommended for the first 24-48 hours.

For treatment of deeper tissues or for prolonged periods of cold application, physician evaluation/prescription is essential to avoid complications.

There are four defined stages of ice therapy.  The first stage is cold, the second is burning/pricking, the third stage is aching, which can sometimes hurt worse than the pain.  The fourth and most important stage is numbness.  As soon as this stage is achieved, remove the ice.  Time duration depends upon body weight.  Twenty to thirty minutes should be the maximum time per area.  If it is necessary to reapply ice, let the skin go to normal temperature or go back to the third stage of aching.

Counter-Indicators and Warnings

Cryotherapy is contraindicated when the following are conditions are present:

• Hypertension (due to secondary vasoconstriction)
• Raynaud disease
• Rheumatoid arthritis / Rheumatism
• Local limb ischemia
• History of vascular impairment, such as frostbite or arteriosclerosis
• Cold allergy (cold urticaria)
• Paroxysmal cold hemoglobinuria
• Cryoglobulinemia or any disease that produces a marked cold pressor response
• Pelvic inflammation
• Sciatica
• Paralysis
• Areas of impaired sensation

Cold packs applied to the abdomen cause increased gastrointestinal motility and gastric acid secretion; therefore, this treatment is contraindicated in those with known peptic ulcer disease.  (Interestingly, application of hot packs to the abdomen produces the opposite effect.)