Ice
- Cooling the body surface with ice is a transfer of energy away from that region
- Lowers local tissue temperature
- Extent of temperature changes in the tissues depends on the rate and amount of heat energy removed
RICER
- Rest
- Ice
- Compression
- Elevation
- Referral
Physiological changes
- Blood flow
- Metabolism
- Peripheral nervous system
- Motor system
- General effects
- Effect on blood flow
Inital vasoconstriction of cutaneous blood vessels (skin blanches)
restriction of blood flow to minimise heat loss
autonomic response from stimulation of
thermoreceptors in the skin
direct effect of smooth muscle in arterioles
dramatic reduction in blood flow through skin
Effect on blood flow cont.
- After 5‐10 mins ‐ vasodilation occurs which may last 15 mins
- then vasoconstriction
- termed “hunting reaction” (vessel ‘hunts’/oscillates around its mean constriction)
- serves to protect tissues from damage
- occurs more readily in the face, buttocks, hands, feet, olecranon
Reduction in muscle blood flow:
• Response of muscle blood flow less dramatic than skin
• Increased blood viscosity and vasoconstriction reduce blood flow in
muscles
• How deeper tissues are cooled will depend on overlying adipose tissue.
• Adipose tissue insulates deeper structures against temperature change
• The location of the tissue being targeted therefore affects the time of application
• Very superficial eg 5‐8 minutes
• Deeper tissue may require longer 10‐20 minutes (and even longer
applications eg ice for 20 mins then a new pack for another 20 mins)
- Reduction in metabolic rate:
- Van’t Hoffs law
- After injury,there are two sources of damage:
- Primary injury – causes cell death and disruption of micro architecture including blood supply
- Secondary hypoxia and post trauma enzyme activity
- Survivingcellsmaybeatriskofhypoxicdeathastheymaybedeprivedof oxygen supply.
- Reduced metabolic rate and rate of necrotic enzyme release and activity at lower temps enhances the survival of these cells
- Reduced metabolic rate‐less O2requirement
- In addition,reduction in oedema reduces secondary damage
- Effect on the peripheral nervous system:
- Strong sensory stimulus activates cold receptors (Aβ and Aδ fibres) – gives pain relief via gating
- Reduces conduction velocity of peripheral nerves particularly Aβ and Aδ fibres
- Strong cold sensation endorphin and encephalin release
- Effect on the motor system:
- Long applications of ice (>30 mins) ‐ reduces muscle strength
- Cooling reduces motor skills and coordination
- Reduction in nerve conduction
- Short applications (< 10 mins) increase isometric muscle strength and endurance
- General effect
- dec. bleeding via constriction and viscosity
- dec. by limiting oedema and pain nerve irritants
- dec. metabolic rate and hence secondary cell necrosis • dec. joint effusion / oedema
Therapeutic uses
Acute soft tissue injuries
• Acute inflammatory joint effusion
• Post‐surgery
• Reduces muscle spasm(due to pain relief)
• Muscle spasticity
• Reflex inhibition of muscle activity
• Affects muscle spindle by prolonged cooling
• Increase viscosity which may diminish rapid stretch reflexes
• Muscle strengthening
• Facilitates a muscle contraction (brief application)
• Short application‐ increase isometric strength
• Chronic inflammation,oedema and joint effusion
• OA/RA in chronic phases
• Long immersions (30 mins) for chronic oedema
• Ice and compression for joint effusion
other uses
• Ice massage for pressure sores
• Ice and stretching (in conjunction with Trigger point therapy – Travell
and Simmons)
Methods of application
1. Ice packs
- Ice pack – crushed ice
- Commercial ice packs
- Single use – endothermic chemical reaction • Reusable gel packs
- Ice wraps
- Ice gels
- Ice sprays
Ice packs cont….
- Flaked ice is folded into a damp towel
- Can use plastic bag inside the towel
- Protect bony prominences
- Frozen peas cool the skin more than gel packs (Chesterton et al 2002) – cheaper and more environmentally friendly.
ice pack types
conventional - 15mins 3.4 > 30mins 6.9˚c
gel pack: 15mins: 1.8˚ >30mins: 4.4˚c
chemical pack: 15mins:1.6˚ >30mins: 2.9˚
- Ice bucket or bath
- Useful for distal extremities
- Immerse between 5‐15 mins.
- Use with caution for too much cooling • May need to remove at intervals
- Ice massage
- small areas eg tendon
- small circular motion
- can also be used to stimulate muscle contraction
- Contrast baths
- Hot and cold water baths
- Hot = 40‐45°C, 3‐4 mins
- Cold = 15‐20°C, 1 min
- To reduce swelling, pain
- Spray and stretch
- Travel and Simmons 1993
- Myofascial techniques and trigger point therapy • Vapocoolant spray
- Passive sustained stretch
Contraindications
Circulatory insufficiency
Exacerbation of existing condition
• Cold Sensitivity
• Vasospasm e.g. Raynauds disease – excessive vasoconstriction in the digital arteries
triggered by cold.
• Cryoglobinaemia
• An abnormal protein is present in blood.
• Can form a precipitate at low temperatures that blocks vessels and causes ischaemia
• Not common but associated with Systemic lupus (SLE) and Rheumatoid (RA)
• Cold Urticaria • ‘cold allergy’
• Cold causes release of histamines from mast cells – local weal and erythema
• Sometimes systemic symptoms such as lowered BP and raised PR
Precautions:
- Unable to communication
- Sensory loss (thermal or anaesthetic)
- Note, sensation test
- If sensory loss, also check capillary return and skin reaction after 5 mins of application
- Emotional and psychological features
danger/precautions
Ice BURNS
- Mild form causes erythema and tenderness for 2‐3 hours after ice
- Severe form ‘ice burn with fatty necrosis’ shows bruising as well and tenderness may last for up to 3 weeks
- Cause is usually from large piece of uncrushed ice directly held against the skin
- Avoid using solid, uncrushed ice application eg. ice cubes or ice bricks
- Always use a damp towel or cloth between ice source and skin
- Rare in the clinical setting but need to monitor
Sensation testing prior to cold therapy
Ice reaction test
• Ice cube massage for 30 seconds OR
• Apply ice pack and check for local response after 5 minutes
• Examine for excessive redness, inflammatory weal or systemic reaction including increased blood pressure or heart rate.
Heat or cold??
- Stage of inflammation
- Collagen extensibility
- Muscle spasm
- Muscle contraction
- Area to be treated
- Ease of use
- Patient preference
