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Use of modalities in rehabilitation

Ice application or cryotherapy


A physical therapist can be extremely effective in helping modify the course of an athletic injury, the timely use of therapeutic technique, tailored specifically to the individual patient condition can alter the event that fellow, some powerful therapeutic tool available to physiotherapist include cold, heat, ultrasound, shockwave, laser therapy (law and high) electric muscles and nerve stimulation (all available in DBC) commonly known as therapeutic modalities.

Application of the appropriate modality at a particular stage of the healing process can prevent undue complication and can save time by preventing an unnecessarily prolonged period of recovery




Ice or cryotherapy is used in the management of acute (24-72 hours) and chronic injuries.

When applied to the human body it creates a number of physiologic responses

the responses vary according to the situation in which cryotherapy is used

the physiological effects are summarized as follows

1. Cellular Metabolism

Lower temperature Decreases metabolic rate, leading to slowing the rate of chemical reaction that occurs as part of tissue metabolism, thereby controls the extent of the inflammatory reaction, reduce the edematous fluid, which allows the exchange of nutrients and cellular waste.


2. Pain



Decease in nerve conduction velocity after the application of cryotherapy is well documented.


Transmission can be slowed by as much as 29.4% after a 20 to 30minute cold application,

With conduction continuing to be impaired to some degree for up to 30 minutes after the cold modality is removed.


It has also been speculated that cold relieves pain through the gate control mechanism by interfering with the transmission of pain impulses at the second-order neurons located in the dorsal root ganglion of the spinal cord. Thus, cold modalities are believed to relieve pain by slowing and reducing the number of pain impulses sent by the peripheral nerves and by interfering with the transmission of the nerve impulses to the brain.


Should NOT be used if suspected or confirmed Complex Regional Pain Syndrome (CRPS)

3. Muscles spasm


Cryotherapy in combination with stretch assists in the reduction of muscles spasm, but attempts to increase the length of cooled muscle could result in tearing of the tissue

4. Inflammation

The effects of cold application on inflammation after traumatic injury are not well investigated, studies on inflammation have shown cryotherapy to mitigate, activate, or ham-per the process in different situations. Cold can stimulate prostaglandin-mediated inflammation and inhibit inflammation that is through to be like traumatically induced inflammation.


5. Circulation

Blood flow obtained the largest changes induced by Cryotherapy.

there is a correlation between cryotherapy time of application and Blood Flow decrease. The longer cryotherapy treatment (25 minutes) had larger Blood Flow decreases compared with the shortest treatment time (5 minutes), the blood flow reduction may result from vasoconstriction is an important physiological response to thermal homeostasis and thermal protection during cold exposure.

The exact physiological mechanism induced by Cryotherapy to promote vasoconstriction is unknown.



Athletes are subjected to treatments that involve the local lowering of the body temperature before, during, and after physical activity. This work reviews the current knowledge regarding the influence of local Cryotherapy on the proprioception system.


The logical assumption from a decrease in nerve conduction velocity as a result of cold application would be that Cryotherapy also decreases proprioception.


The reviewed literature identified several tests that evaluate different aspects of proprioception. The outcomes of different tests and assessments of cryotherapy procedures using different cold modalities are poorly correlated. In general, the published results on the mechanism of cryotherapy effects on proprioception are not uniquely conclusive and are frequently contradictory.


Muscles Strength


Joint Cryotherapy can be a tool to muscles activation and strengthening for the patient with joint pathology, it’s suggested to use joint Cryotherapy prior to exercise to increase motor neuron activation that provides more neural drive to the neuromuscular junction resulting in greater muscles strength

Considerations for use


In using the cold modalities, the physiotherapist must consider ways to avoid undercooling, which does not achieve the desired result, and overcooling, which risks tissue damage.

To cool segment of tissue effectively the modality must be cold enough,

must cover a sufficiently large area.


Must be located over tissue with a thermal conductivity that allows heat to transfer to the surface therefor ice pack containing chipped ice is strongly recommended because they remain at 0 degrees until all the ice melts.


Ligaments, muscles, and bone all have thermal conductivities that allow the cooling of the tissue after topical ice application.


Fat is an excellent insulator, with thermal conductivity less than half of the other tissues,

researches have shown that the thickness of the subcutaneous fat layer between the skin and muscle being cooled for a patient with substantial subcutaneous fat, effective cooling can take a long time.


Application




· Ice packs

· The greatest advantage of an ice pack is their ability to mention a constant temperature at 0 degrees

· Ice bath, full-body immersion

· Cooling gel pack

· Cool spray

· Ice massage

More recently whole-body Cryotherapy has become popular for athletes, to help aid recovery, as well as in persistent pain patients such as rheumatological conditions. More research is needed to understand the effect on the body and its relation to pain.


Possible Risks

Inhibit Muscle Function

Cooling can temporarily Inhibit muscle function in a healthy person with potential for increased risk of injury/re‐injury

Be cautious when having patients undertake complex exercise after icing a lower extremity

Ice Burn


Elderly patients with impaired sensation and/or circulation will be more vulnerable to an ice‐burn, therefore consider using less intense icing techniques (cold ice pack wrapped in a toweling’s)

Cold gel packs stored in a freezer have a surface temperature below 0°C (32°F) and thus an insulating layer should be used between the cold pack and the patient’s skin

CryotherapyInduced Nerve Injuries

Most common when cold is applied in combination with compression

Check capillary refill during application of ice combined with compression therapy to ensure adequate blood flow

Generalized Cooling and Decrease in Core Temperature

Shivering is signs of a decrease in core temperature which may compromise patient safety (especially in the elderly and those with fever)

The application of therapeutic Cryotherapy should produce only local effects

Reduced ROM

Ice may contribute to the shortening of collagen fibers in connective tissue

If one wishes to cool the tissue post stretch and exercise, it is best to do so with the tissue in a lengthened position

In patients with significantly restricted ROM due to scar tissue, it may be preferable not to use ice

Contraindications

Be aware of conditions in which icing is contraindicated

Raynaud’s disease, which ice application cause peripheral vasoconstriction which results in tissue schema

Patient with cold allergy cold application cause skin redness, flushing of the face, decrease blood pressure, increase heart rate and fainting

Cryoglobulinemia, cold cause blood to gel when cold is applied

Cold hemoglobinuria, intros patient cold cause breakdown in red blood cell resulting in blood in the urine

Cold-induced urticaria and slowed wound healing.

Conclusion


Cold therapy or Cryotherapy is a popular treatment method for sports injuries. It is important first aid for acute (sudden onset) sports injuries as well as being beneficial for the long term, chronic injuries. explained when to use cold therapy, its benefits, as well as when it is not safe (contraindicated) to apply ice.

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