Sports Medicine: Just the Facts

CHAPTER 68 • PHYSICAL MODALITIES IN SPORTS MEDICINE 409

THERAPEUTIC COLD

• The cooling agents are often used for their analgesic,
  metabolic, and perfusion-limiting effects.


• Cooling therapies are restricted to conductive and
  convective means.

GENERAL INDICATIONS

• Acute musculoskeletal trauma
  •Pain


• Muscle spasm


• Spasticity


• Reduction of metabolic activity

GENERAL CONTRAINDICATION
AND PRECAUTIONS

•Ischemia

• Insensitivity


• Cold intolerance


• Raynaud’s phenomenon and disease
  •Severe cold pressor responses


• Cold allergy

PHYSIOLOGY OF CRYOTHERAPY

• Superficial cold produces analgesia (Hartviksen,
  1962), reduces metabolic activity, slows and may
  block nerve conduction (Denys, 1991), decreases
  muscle tone and spasticity (Knight, 1985; Knutsson
  and Mattsson, 1969; Miglietta, 1973), and increases
  gastrointestinal motility (Bisgard and Nye, 1940).


• Ice is the most common cryotherapy agent.


• Skin temperatures initially fall rapidly following the
  application of ice and then decreased more slowly
  toward an equilibrium value of 12 to 13°C.


• Long periods have a more pronounced effect. Ice
  cooling for 20 to 180 min can lower relatively super-
  ficial intramuscular temperatures by 6 to 16°C
  (Denys, 1991; Dussick et al, 1958; Knight, 1985;
  Lehmann and de Lateur, 1982).
  a. In one study, knee intra-articular temperatures
  decreased by 6°C after being packed in ice for 3 h.
  Likewise, blood flow decreased by 20 and 30% in
  bone and soft tissue, respectively, after 25 min
  (Oosterveld and Rasker, 1994).
  b.Reduces conduction velocity.
  c. Inhibits the release of histamine.
  d. Slows chemical reactions.

e. Relative hyperemia after cold application stimu-

lates tissue repair and healing.

• Technique:Ice packs, compression wraps are most
  common.


• Sessions typically last 20 to 30 min.


• Ice massage is a vigorous approach suitable for lim-
  ited portions of the body. A piece of ice is rubbed over
  the painful area for 7 to 10 min.


• Iced whirlpools cool large areas vigorously.
  •Vapocoolant and liquid nitrogen sprays produce large
  (as much as 20°C), rapid drops in skin temperature
  and are used at times to produces superficial analgesia
  as well as in spray and stretchtreatments (Oosterveld
  and Rasker, 1994; Travell, 1952).


• Chemical ice packs are also common.

TRAUMAINDICATIONS

• Cooling applied soon after trauma may decrease
  edema, lessen metabolic activity, reduce blood flow,
  lower compartmental pressures, diminish tissue
  damage, and accelerate healing (Ho et al, 1995; Basur,
  Shephard, and Mouzas, 1976; Moore and Cardea,
  1977; Schaubel, 1946; Bert et al, 1991; Hirase, 1993).


• Rest, ice, compression, and elevation(RICE) are the
  mainstay of treatment


• Cyclic ice application is often recommended (e.g.,
  20 min on, 10 min off; or 30 min on, 2 h off) for 6 to
  24 h (Hartviksen, 1962; Knight, 1985; Sloan, Hain,
  and Pownall, 1989; Hocutt et al, 1982).


• Opinions regarding usefulness of cryotherapy for
  injuries more that 24 to 48 h old are divergent.

PRECAUTIONS ANDCONTRAINDICATIONS

• When sensation is compromised, circulation is
  impaired, or tissues are compressed (Barlas, Homan,
  and Thode, Jr, 1996).


• Rare but possible problems include pressor responses
  aggravating cardiovascular disease, Raynaud’s phe-
  nomenon, cold hypersensitivity, urticaria, and cold
  allergy/cryoprecipitation.

ELECTROTHERAPY

GENERALINDICATIONS

•Today, high-intensity electrical stimulation is used to

strengthen muscles and to move paralyzed limbs.

• Less-intense stimulation produces analgesia and
  delivers medications percutaneously.


• Stimulation at still lower intensities has gained FDA
  approval for fracture healing.


• Soft-tissue wounds, osteoporosis, and musculoskele-
  tal pain represent additional potentially important, but
  still investigational, applications.