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If you decided to use an ice pack on the sprinter, how long should you apply the ice?

If you decided to use an ice pack on the sprinter, how long should you apply the ice? What contraindications may prohibit you from using this modality on the individual?


Cryotherapy describes multiple types of cold application that use the type of electromagnetic energy classified as infrared radiation. When cold is applied to skin (warmer object), heat is removed or lost. This is referred to as heat abstraction. The most common modes of heat transfer with cold application are conduction and evaporation. Cold application for less than 15 minutes causes immediate skin cooling, cooling of subcutaneous tissue after a slight delay, and a longer delay in cooling muscle tissue (2). Depth of cold penetration can reach 5 cm (1). 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 (2) 

The greater the temperature gradient between the skin and cooling source, the greater the resulting tissue temperature change. Likewise, the deeper the tissue, the longer the time required to lower the temperature. Adipose (fat) tissue acts as an insulator and resists heat transfer; both heat gain and heat loss. The amount of adipose tissue influences the degree and rate at which muscle is cooled, and conversely, return to its precooled temperature. 

    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 inhibited. As the temperature of peripheral nerves decreases, a corresponding decrease is seen in nerve conduction velocity across the nerve synapse, thus increasing the threshold required to fire the nerves. The gate theory of pain hypothesizes that cold inhibits pain transmission by stimulating large-diameter neurons in the spinal cord, acting as a counterirritant, which blocks pain perception. Because of the inhibition of nerves and muscle spindle activity, muscles in spasm are relaxed, breaking the painspasm cycle, leading to an analgesic, or pain-free, effect. Research also has shown that during ice application, a decline in fast-twitch muscle fiber tension occurs, resulting in a more significant recruitment of slow-twitch muscle fibers, thereby increasing muscle endurance (3). 

    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 to 18.3C (32 to 65F) (1). However, researchers have identified that maximal decreases in localized blood flow can occur at temperatures ranging from 12.83 to 15C (55 to 59F) (4,5). The desired 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. Recent technology also has provided new forms of cold application such as the Cryocuff, or controlled cold therapy (CCT) units. 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 (6,7). Ice application is continued during the first 24 to 72 hours after injury, or until acute bleeding and capillary leakage have stopped, whichever is longer. Another consideration is the length of time it takes to rewarm the injured area. Knight has shown that except for the fingers, the rewarming time to approach normal body temperature is at least 90 minutes (7). This results in a treatment protocol of applying an ice pack for 20 to 30 minutes, followed by 90 minutes of rewarming. Fingers can rewarm more quickly, even following a 20- to 30-minute ice treatment, presumably because of their increased circulation. Fingers need only 20 to 30 minutes to rewarm. 

    Cold therapy has long been used after arthroscopic knee surgery. Although some researchers have found that the addition of cryotherapy to a regimen of exercises following arthroscopic knee surgery did produce some benefits of increased compliance, improved weight-bearing status, and lower prescription medication consumption (8), other researchers have shown that this use of cold therapy is questionable (9,10). 

    Certain methods of cryotherapy also may be used prior to ROM exercises and at the conclusion of an exercise bout (Box 7.2). 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 (generally 10 to 20 minutes of immersion), 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 a 3- to 5-minute cold treatment. The exercise bout is repeated three to four times each session. The session then ends with exercise if the individual is able to 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.


Cryotherapy Application



Acute or chronic pain

Acute or chronic muscle


Acute inflammation or injury

Postsurgical pain and edema

Superficial first-degree burns

Used with exercises to:Facilitate mobili-zation

Relieve pain

Decrease muscle


Decreased cold sensitivity and/or hypersensitivity

Cold allergy

Circulatory or sensory


Raynaud’s disease or cold urticaria


Uncovered open wounds

Cardiac or respiratory


Nerve palsy


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 hyperemia, 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 (2). 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 10*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 15C (59F) (2). 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 and Contoured Cryocuffs

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 molded 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 (Figure 7.5A). During the initial treatments,the skin should be checked frequently for wheal or blister formation (Figure 7.5B).

     Contoured Cryocuffs use ice water placed in an insulated thermos. When the thermos is raised above the body part, water flows into the Cryo Pack, maintaining cold compression for 5 to 7 hours (Figure 7.6). Although more expensive than ice packs, these devices combine ice and compression over a longer period without threat of frostbite.


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