Cryotherapy describes multiple types of cold application. When cold is applied to skin, heat is generally lost. The common methods of heat transfer while using cold application are conduction and evaporation. Cold application for less than 15 minutes causes immediate skin cooling. Whereas cooling of subcutaneous tissue occurs after a slight delay, and a longer delay in cooling muscle tissue. The depth of cold penetration can reach 5 cm. The magnitude of temperature change depends on:

1. Type of cooling agent (e.g., ice versus water)
2. Temperature difference between the cold object and tissue
3. Amount of subcutaneous insulation (fat)
4. Thermal conductivity of the area being cooled
5. Limb circumference
6. Duration of the application

The greater the temperature gradient between the skin and cooling source, the greater the resulting tissue temperature change. Similarly, deeper the tissue, longer the time needed to lower the temperature. Adipose tissue acts as an insulator and delays heat transfer, both heat gain and loss.

Cold application leads to vasoconstriction at the cellular level and decreases tissue metabolism (i.e., decreases the need for oxygen), which reduces secondary hypoxia. Capillary permeability and pain are decreased, and the release of inflammatory mediators and prostaglandin synthesis is also inhibited. As the temperature of peripheral nerves decreases, a corresponding decrease is seen in nerve conduction velocity also, thus increasing the threshold required to fire the nerves.

Because of the inhibition of nerves and muscle spindle activity, muscles in spasm are relaxed, breaking the pain spasm cycle, leading to an analgesic, or pain-free, effect. Because vasoconstriction leads to a decrease in metabolic rate, inflammation, and pain, cryotherapy is the modality of choice during the acute phase of an injury. According to Starkey, the therapeutic application of cold ranges in temperature from 0 degree to 18.3 degree C (32 to 65^oF). However, researchers have identified that maximal decreases in localized blood flow can occur at temperatures ranging from 12.83^o to 15^oC (55^o to 59^oF).

The therapeutic range of cooling can be obtained through the use of ice bags (crushed or cubed), commercial ice packs, ice cups (ice massage), cold water baths (immersion or whirlpool), and vapo-coolant sprays. Cryotherapy is usually applied for 20 to 30 minutes for maximum cooling of both superficial and deep tissues. Barriers used between the ice application and skin can affect heat abstraction. Research has shown that a dry towel or dry elastic wrap should not be used in treatment times of 30 minutes or less. Rather, the cold agent should be applied directly to the skin for optimal therapeutic effects. Cold therapy has long been used after arthroscopic knee surgery. Use of cold treatments before exercise is called cryokinetics.

Cryokinetics alternates several bouts of cold using ice massage, ice packs, ice immersion, or iced towels with active exercise. The injured body part is numbed, and the individual is instructed to perform various progressive exercises. These exercises may begin with simple, non–weight bearing ROM activities and progress to more complex, weight-bearing activities. All exercise bouts must be pain free. As the mild anesthesia from the cold wears off, the body part is renumbed with 3 to 5 minutes of cold treatment. The exercise bout is repeated three to four times each session. The session then ends with exercise if the individual can participate, or with cold if the individual is not able to participate in practice. Methods of cryotherapy include ice massage, ice and cryo packs, ice immersion and cold whirlpools, commercial gel and chemical packs, controlled cold compression units, and vapo-coolant sprays. With each method, the individual experiences four progressive sensations: cold, burning, aching, and finally analgesia.

INDICATIONS

1. Acute & Chronic Pain.
2. Acute & Chronic muscle spasm.
3. Acute inflammation or injury.
4. Post-surgical pain and oedema.
5. Superficial first-degree burns.
6. Used in exercise for mobilization, relieve pain, decrease muscle spasm,

CONTRAINDICATIONS

1. Hyper sensation
2. Cold allergy
3. Circulatory or sensory impairment.
4. Raynaud’s diseases.
5. Hypertension4nerve palsy
6. Arthritis

ICE MASSAGE

Ice massage is an inexpensive and effective method of cold application. Performed over a relatively small area, such as a muscle belly, tendon, bursa, or trigger point (localized area of spasm within a muscle). It produces significant cooling of the skin and a large reactive hyperaemia, or increase of blood flow into the region, once the treatment has ended. As such, it is not the treatment of choice in acute injuries. Ice massage is particularly useful for its analgesic effect in relieving pain that may inhibit stretching of a muscle and has been shown to decrease muscle soreness when combined with stretching. It is commonly used prior to ROM exercises and deep friction massage when treating chronic tendinitis and muscle strains.

Treatment consists of water frozen in a cup, then rubbed over an area of 10 to 15 cm in small, overlapping circular motions for 5 to 10 minutes. A continuous motion is used to prevent tissue damage. If done properly, skin temperature should not decrease below 15^oC (59^oF). A wooden tongue depressor frozen in the cup provides a handle for easy application. With ice massage, the stages of cold, burning, and aching pass rapidly within about 1 to 2 minutes. A prolonged aching or burning sensation may result if the area covered is too large, or if a hypersensitive response occurs.

ICE PACKS

Ice packs are inexpensive and maintain a constant temperature, making them very effective in cooling tissue. When filled with flaked ice or small cubes, the ice packs can be safely applied to the skin for 30 to 40 minutes without danger of frostbite. Furthermore, ice packs can be moulded to the body’s contours, held in place by a cold compression wrap, and elevated above the heart to minimize swelling and pooling of fluids in the interstitial tissue spaces.

ICE IMMERSIONS

Ice immersion is used to reduce temperature quickly over the entire surface of a distal extremity (forearm, hand, ankle, or foot). Because of the analgesic effect and buoyancy of water, ice immersion and cold whirlpools often are used during the inflammatory phase to reduce oedema formation after any blunt injury. Cold whirlpool baths also provide a hydro massaging effect. This is controlled by the amount of air emitted through the electrical turbine. The turbine can be moved up and down or directed at a specific angle and locked in place. The whirlpool turbine should not be operated unless water totally covers the impeller. In addition to controlling acute inflammation, cold whirlpools can be used to decrease soft-tissue trauma and increase active ROM after prolonged immobilization. If the goal is to reduce edema, placing the body part in a stationary position below the level of the heart keeps fluid in the body segment and is contraindicated. This can be avoided by placing a compression wrap over the body part prior to submersion and doing active muscle contractions. Neoprene toe caps may be used to reduce discomfort on the toes. Bucket immersion in 40^o to 50^oF of water or a 50^o to 60^oF of whirlpool cools tissues as effectively as an ice pack. The lower the temperature, the shorter the duration of immersion. Treatment lasts from 5 to 15 minutes. When pain is relieved, the part is removed from the water and functional movement patterns are performed. As pain returns, the area is reimmersed. The cycle continues three to four times.

CONTRAST BATH

A contrast bath alternates cold and hot tubs or whirlpools. This elicits a local vasoconstriction-vasodilation fluctuation to reduce edema and restore ROM in subacute or chronic injuries. Two whirlpools or containers are placed next to each other. One is filled with cold water and ice at 10^o to 18^oC and the other is filled with hot water at 38^o to 44^oC. The injured extremity is alternated between the two tubs. One treatment method involves a 3:1 or 4:1 ratio (hot water to cold water) for approximately 20 minutes. In subacute conditions, the treatment begins and ends in cold water prior to starting therapeutic exercise. In chronic conditions, treatment is more often concluded in warm immersion. A second method is to base treatment on a variable time frame. During the first cycle, 75% of the time is in cold water and 25% of the time is in hot water. The second cycle moves to 50% in cold water and 50% in hot water, with the third cycle moving to 25% in cold and 75% in hot water. However, research has failed to demonstrate any significant physiologic effect on intramuscular tissue temperature 1 cm below the skin and subcutaneous fat. Therefore, contrast therapy may need to be reconsidered as a viable therapeutic modality.

COMMERCIAL GEL AND CHEMICAL PACKS

Commercial gel packs are composed of a flexible gelatinous substance enclosed in a strong vinyl or plastic case and come in a variety of sizes to conform to the body’s natural contours. Used with compression and elevation, they are an effective cold application. The packs are stored at a temperature of about –5^oC for at least 2 hours prior to application. Because the packs are stored at sub-zero temperatures, they may cause frostbite if used improperly. A wet towel or cloth should be placed between the pack and skin to prevent frostbite and maintain a hygienic surface for the reusable packs. Treatment time is 15 to 20 minutes. Chemical packs can be advantageous because they are convenient to carry in a training kit, disposable after a single use, and conform to the body part. A disadvantage of the packs is their expense. The packs are activated by squeezing or hitting the pack against a hard area. The chemical substance has an alkaline pH and can cause skin burns if the package breaks and the contents spill.  As such, the packs should never be squeezed or used in front of the face, and if possible, should be placed inside another plastic bag. Treatment ranges from 15 to 20 minutes. In longer treatments, the pack warms and becomes ineffective. Some commercial packs can be refrozen and reused.

INTERMITTENT COMPRESSION UNITS

Intermittent cold-compression units use compression and elevation to decrease blood flow to an extremity and assist venous return, thus decreasing edema. A boot or sleeve is applied around the injured extremity. Cooled water is circulated through the sleeve. Compression is formed when the sleeve is inflated intermittently. This is done for 20 to 30 minutes, several times a day, to pump edema fluid from the extremity. During deflation, the patient can do active ROM exercises to enhance blood flow to the injured area. The unit can be used several times a day but should never be used with a suspected compartment syndrome or fracture, or in an individual with a peripheral vascular disease or impaired circulation.

VAPO COOLANT SPRAYS

Fluor methane is a non-flammable, nontoxic spray that uses rapid evaporation of chemicals on the skin area to cool the skin prior to stretching a muscle. The effects are temporary and superficial. When using a vapo-coolant spray to increase ROM in an area where no trigger point is present, the patient is comfortably positioned with the muscle passively stretched. The bottle of vapo-coolant spray is then inverted and held at a 30⁰ to 45^o angle and sprayed approximately 12 to 18 inches away from the skin. The entire length of the muscle is sprayed two to three times in a unidirectional, parallel sweeping pattern as a gradual stretch is applied by the clinician.

When using this spray to treat trigger points and myofascial pain, the clinician must first determine the presence of an active trigger point. This is accomplished by putting the muscle under moderate tension, followed by application of firm pressure over the painful site for 5 to 10 seconds. Another technique involves eliciting a jump response. This method also involves placing the muscle under moderate tension. Firm pressure is applied over the tense muscle, and a finger is pulled across the tight band of muscle. If the individual winces or cries out, an active trigger point is present. The individual is then placed in a relaxed, but well-supported position with the involved muscle placed on stretch. The vapo-coolant spray is sprayed from about 12 inches above the skin at an acute angle to the painful site. The entire length of the muscle is sprayed, including the painful site, while the clinician begins a mild passive stretch of the involved muscle, within the patient’s tolerance. After several parallel sweeps of the muscle and continued passive stretching, the muscle should be warmed with a hot pack or vigorous massage. The patient should be encouraged to move the body part actively but gently throughout the full ROM. The process may need to be repeated; however, it is critical not to overload the muscle with strenuous exercise immediately after the session.

MASSAGE

Massage involves the manipulation of soft tissues to increase cutaneous circulation, cell metabolism, and venous and lymphatic flow to assist in the removal of oedema, stretch superficial scar tissue, alleviate soft tissue adhesions and decrease neuromuscular excitability. As a result, relaxation, pain relief, oedema reduction, and increased ROM can be achieved. To reduce friction between the patient’s skin and hand, particularly over hairy areas, lubricants (i.e., massage lotion, peanut oil, coconut oil, or powder) can be used. These lubricants should have a lanolin base or be alcohol free. Massage involves five basic strokes: effleurage (stroking), petrissage (kneading), tapotement (percussion), vibration, and friction.

Effleurage is a superficial, longitudinal stroke to relax the patient. When applied toward the heart, it reduces swelling and aids venous return. It is the most commonly used stroke, and begins and ends each massage. Effleurage permits the clinician to evaluate the condition, distribute the lubricant, warm the skin and superficial tissue, and promote relaxation.

Pétrissageconsists of pressing and rolling the muscles under the fingers and hands. This “milking” action over deep tissues and muscle increases venous and lymphatic return, and removes metabolic waste products from the injured area. Furthermore, it breaks up adhesions within the underlying tissues, loosens fibrous tissue, and increases elasticity of the skin.

Tapotement uses sharp, alternating, brisk hand movements such as hacking, slapping, beating, cupping, and clapping to increase blood flow and stimulate peripheral nerve endings. Because this technique is used for stimulation, not relaxation, it is not used in most massage

treatments.

Vibration consists of finite, gentle, and rhythmical movement of the fingers to vibrate the underlying tissues. It is used for relaxation or stimulation.

Friction is the deepest form of massage, and consists of deep circular motions performed by the thumb, knuckles, or ends of the fingers at right angles to the involved tissue. These deep circular movements can loosen adherent fibrous tissue (scar), aid in absorption of edema, and reduce localized muscular spasm. Transverse friction massage is a deep friction massage performed across the grain of the muscle, tendon sheath, or ligament. Crossfriction massage is the most effective technique, and is used to break up adhesions and promote healing of muscle and ligament tears.

MANIPULATION

Manipulations and mobilisations are manual techniques used to physically affect a joint. If you are feeling joint pain or stiffness your physiotherapist may decide that manipulations or mobilisations are the best course of treatment. There are a wide range of techniques that can be used to move a joint to increase its movement. Manipulations and mobilisations get the joint moving. This often takes place with the individual in a relaxed position. This allows the physiotherapist to move the joint within the desired range. This will achieve movement of the joint that would not be possible by the patient alone due to pain. The manipulation or mobilisation gets the joint moving which can:

• Reduce stiffness
• Reduce pain
• Increase range of movement
• Increase function

STRETCHING

Definition: –

It is the elongation of the pathologically shortened or tightened soft tissues with the help of some therapeutic techniques. There are 3 different types of stretching, they are Passive stretching, PNF and Self – stretching.

1. Passive Stretching

Manual

Mechanical

• Manual Stretching:

This is normally performed by the physician or by the therapist. The stretching may be given for 15 – 30 sec, sometimes it may extend upto about 60 seconds. The stretching duration and the force applied may change depending on the condition and the tolerance power of the patients. It is basically of 2 types

Static Stretching – a Slow and prolonged stretch is appled to avoid the reflex contraction from the muscle spindle and golgi tendon organ. In this stretch, the muscle is elongated gently and maintained for a long period without any pain. The muscle fiber undergoes constant relaxation and flexibility.

Ballistic Stretching – it is the bouncing or jerky type of stretching. It is a high velocity and short duration stretching. It can be done actively. Even though the ballistic stretching increases the flexibility. It may cause injury because the movements may exceed the limits of extensibility ans it has poor control over the movements. This type of stretching causes the mictrotrauma in themuscle and connective tissues, apart from increasing their flexibility earlier.

• Mechanical Stretching

This is also divided into 2, long duration mechanical stretching and cyclic mechanical stretching.

Long duration mechanical stretching – here low intensity stretches are given for a long period of time. This gives mioreflexibitity in the muscles. The stretch given from 20 minutes to several hoyurs, gives good effect than the stretch applied for less than 20 minutes. This stretch is usually provided by external force in low intensity for loinger duration with the help of mechanical instruments.

Cyclic mechanical stretching – here mechanical devices are used to provide stretch in cyclic manner. The intensity of stretch, duration of stretch and number of stretch cycle per minute can be set in the mechanical device itself.

INDICATIONS

Post traumatic stiffness, post immobilization stiffness, restrictive mobility, congenital or acquired bony deformity, joint pathology resulting in soft tisse stiffness, soft tissue pathology resulting in soft tissue stiffness, soft tissue pathology leading to relative soft tissue stiffness, healed burn scars, fear of pain spasm, adhesion formation over soft tisse, contracture of the joint and soft tissue, any type of muscular spasm, spasticity.

CONTRAINDICATIONS

Synovial effusion. Recent fracture, shar[p pain while doing stretch, inflammation in the tight tissue, infection over tight tissue, iommediately after dislocation, oedema, osteoporosis, hemophilic joint, malignant tumors, Unhealed ulcers and scars, chronic rheumatoid arthritis.

HOW TO ACHIEVE EFFECTIVE STRETCHING?

Some of the physical modalities are helpful to increase the effect of stretching. Theassistive modality that increases the quality of stretch can be given before the stretching regime. Some of these modalities being

• Heat
• Masaage
• Oscillation
• Joint mobilization
• Active exercise.