Peripheral Blood Flow & Temperature Modulations after Common Cryotherapy Treatments.

1. Peripheral Blood Flow & Temperature Modulations after Common Cryotherapy Treatments. John Rich, ATC

2. Ankle Anatomy • Talocrural Joint • Lateral Collateral Ligaments • Anterior talofibular ligament (ATF) • Posterior talofibular ligament (PTF) • Calcaneofibular ligament (CF) • Deltoid ligament (Medial) • Dorsiflexion • Plantarflexion

3. Ankle Anatomy • Subtalar Joint • Articulation between the talus and calcaneous • Inversion • Eversion

4. Ankle • Most ankle injuries are ankle sprains • Inversion Sprains • Eversion Sprains • Syndesmotic Sprains

5. Facts • 23,000 ankle sprains/day3 • 1 sprain/10,000 people • Severity often underestimated4 • current treatments may not prevent reoccurring injuries

6. Cryotherapy • One of the most commonly used treatments • Ice Bags • Instant and Gel Ice Packs • Ice Immersion • Cold Whirlpool • Theragesic Agents • Ice Massage • Reduces inflammation, pain, and muscle spasm2 • Cooling effects of both superficial and intramuscular tissues

7. Cryotherapy Physiologic Changes2 Vasoconstriction Decreased metabolism Decreased Spasm and edema formation Decreased Pain sensation Lasting effects of cold play a role in the healing process Limiting inflammation An optimal environment for healing

8. Cryotherapy An essential component to the initial treatment of acute injuries Limited research to examine the role of elevation in vascular and temperature changes during cryotherapy

9. Cryotherapy Techniques • RICE (Rest, Ice, Compression, Elevation) technique • The ‘Wrap and Go’ ice bag technique

10. Infrared Thermography • Infrared thermography (DIRT) • Non-invasive method of collecting real time temperatures of tissues up to 2 inches in depth5 • Averages temperatures of a specific area • Spot specific measurements with a thermocouple

11. Infrared Thermography A valid and reliable tool for measuring tissue temperature Tracks dynamic changes in tissue temperature Ideal tool for monitoring recovery of tissue temperature The physiological changes following cryotherapy can be measured and can remain consistent

12. Research • A similar study comparing cryotherapy while treadmill walking and while lying prone • Not much research comparing ice and elevation • Surface temperature changes will occur but will position or activity effect vascular changes at the joint

13. Purpose Compare the physiological effects of ice with elevation, and ice with a sub-maximal movement (walking), and how elevation alone will effect the healing process. To determine the cooling effects of skin temperature and the peripheral blood flow at the lateral ankle joint.

14. Hypothesis The “wrap and go” technique will provide the therapeutic effects necessary for healing. The RICE method will produce more beneficial therapeutic effects that will last longer after the ice is removed, allowing for more decreased inflammation and healing time.

15. Study Design • A 2x3x3 repeated measures factorial experimental design. • Independent variables: • Treatment • Ice • No Ice • Position • No-elevation • Elevation • Treadmill Walking • Time • Pre-Test • Initial Post-Test • 15-Min Post-Test • Dependent variable • Skin Temperature

16. Participants • 12 participants (6 males  = 23.5 years, 6 females  = 21.5 years) • Criteria • No injury • Medical PAR-Q • Cold hypersensitivity or known cold allergies • IRB approved

17. Instrumentation • Thermal Image Processor (TIP) • Infrared camera used to capture and analyze images, utilizing advanced image analysis software, TIPMED • Xpress compact scale • To accurately measure each ice bag (1kg)

18. Instrumentation Heavy duty ice bags (9 ½” x 18”) Cramer Flexi-Wrap (4”) Hand crafted devices for no-elevation and elevation treatments

19. Procedures Total of 18 images Over 5 days, within a 2 week time period Each session lasted about 45 minutes to 1 hour

20. Protocol • Equilibration for 15 minutes • Pre-Image taken • 15 minute Treatment • Initial Post-Image taken • Sit for 15 minutes • 15-minute Post-Image taken

21. Protocol – cont. Day One Day Two No-Elevation No Ice Elevation No Ice Treadmill No Ice Day Four Day Three Day Five No-Elevation Ice Elevation Ice Treadmill Ice

22. Images 15 Minutes after the treatment Before Treatment Pre 15 Mins. Post Immediately following the treatment Initial Post

23. Statistical Analysis • All data was inserted into a custom Excel spread sheet (Version 2007) • Analysis of Variance (ANOVA) • Follow up t-tests • Statistical Package for the Social Sciences (SPSS version 16) • The alpha level was set a priori at p = 0.05

24. Results • A significant interaction between treatment and time [F(2,10) = 0.923, p < 0.0001] and position and time [F(2,10) = 0.923, p < 0.003] • No interaction between treatment and position [F(2,10) = 0.923, p = 0.429] • Position did have a within-subjects effect with ice treatment (p = 0.026)

25. TABLE 1. Temperature by condition (oC); pre-test, initial post-test, & 15 minutes post-test (Mean ±SD)

26. TABLE 2. Temperature by condition; with and without Ice Treatment; Pre-test & 15 minutes post-test (Mean ±SD, 95% confidence intervals (CI) and effect size (ES)

27. Results/Discussion • Immediately following 15 minutes of ice bag application, the treadmill walking condition showed cooler superficial temperatures than the no-elevation condition (p = 0.056) • Means indicate a difference in non-contact surface temperatures of about 2oC • Ice Massage and Ice Bag • Ice Massage cools quicker then Ice Bag • Greater pressure applied • Continuous movement and friction

28. Discussion • Circulation plays an important role in determining tissue temperature of the treatment area. • The Hunting Response • First produces vasoconstriction, helping reduce the flow of cold blood to the core • A reflex vasodilation occurs producing an increase in circulation bringing warm blood to the area • A pulsed circulation effect • If cold is continuously applied for fifteen to thirty minutes, an intermittent period of vasodilation occurs every four to six minutes. 10

29. Results/Discussion • The treadmill walking seems to produce a quicker return to baseline (warm-up) than the elevated position (p = 0.02) • No-elevation to Elevation (p = 0.34) • Treadmill walking to No-elevation (p = 0.26) • The application of cryotherapy produces physiologic changes in the tissue.7 • Thus, when exercising during the treatment the cooling effect of the cryotherapy on the muscle is negated by the heat produced by the muscle activity.2

30. Discussion • This study only looked at the effects in the lower extremity • Research needs to be conducted to investigate the differences between joints and muscles • Limitations • Intra-joint temperatures • Temperature and humidity

31. Conclusion • The ‘wrap and go’ technique of cryotherapy may be beneficial in decreasing surface temperature but tends to re-warm quicker, suggesting the traditional RICE method is more appropriate for effective cryotherapy treatments.

32. Acknowledgements • A special thank you to: • Dr. Pascoe • Dr. Sefton • Ceren • The Fellows • The Kenny Howard Fellowship

33. References Ingersoll CD, Knight KL, Merrick MA. Sensory perception of the foot and ankle following therapeutic applications of heat and cold. J Ath Train. 1992;27:231-234. Mattacola CG, Dwyer MK. Rehabilitation of the ankle after acute sprain or chronic instability. J Ath Train. 2002;37:413-429. Wikstrom EA, Arrigenna MA, Tillman MD, Borsa PA. Dynamic postural stability in subjects with braced, functionally unstable ankles. J Athl Train. 2006;41:245-250. Bender AL, Kramer EE, Brucker JB, Demchak TJ, Cordova ML, Stone MB. Local ice-bag application and triceps surae muscle temperature during treadmill walking. J Ath Train. 2005;40:271-275. Hardaker NJ, Richards MJ, Jarvis S, McEwan I, Selfe J. The relationship between skin surface temperature measured via non-contact thermal imaging and intra-muscular temperature of the rectus femoris muscle. Thermology. 2007;17;45-50. Zemke JE, Anderson JC, Guion WK, et al. Intramuscular temperature responses in the human leg to two forms of cryotherapy: ice massage and ice bag. J Ortho Sports Phys Ther. 1998;27;301-307. Kennet J, Hardaker N, Hobbs S, Selfe J. Cooling efficiency of 4 common cryotherapeutic agents. J Ath Train. 2007;42:343-348. Merrick MA, Knight KL, Ingersoll CD, Potteiger JA. The effects of ice and compression wraps on intramuscular temperatures at various depths. J Ath Train. 1993;28;236-245. MacAuley DC. Ice therapy: How good is the evidence? Int J Sports Med. 2001; 379-384. Prentice WE. Arnheim’s Principles of Athletic Training: A Competency-Based Approach. 11th ed. New York, NY: McGraw-Hill; 2003. Bleakley CM, O’Connor S, Tully MA, Rocke LG, MacAuley DC, McDonough SM. The PRICE study (protection rest ice compression elevation): design of a randomized controlled trial comparing standard versus cryokinetic ice applications in the management of acute ankle sprain. BMC MusculoskeletDisord. 2007;8:125; 1-8. Atnip BL, McCrory JL. The effect of cryotherapy on three dimensional ankle kinematics during a sidestep cutting maneuver. J Sports Sci Med. 2004;3:83-90. Beynnon BD, Murphy DF, Alosa DM. Predictive factors for lateral ankle sprains: A literature review. J Ath Train. 2002;37:376-380. Hawkins JR, Knight KL, Long BC. Are room temperature and thermal neutral synonymous terms? An investigation of common therapeutic modality control variables. J Ath Train. 2007;42:327-332. Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train. 2002;37:364-375. Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft tissue injury? J Ath Train. 2004;39:278-279. Jutte LS, Merrick MA, Ingersoll CD, Edwards JE. The relationship between intramuscular temperature, skin temperature, and adipose thickness during cryotherapy and rewarming. Arch Phys Med Rehabil. 2001;82:845-850. Otte JW, Merrick MA, Ingersoll CD, Cordova ML. Subcutaneous adipose tissue thickness alters cooling time during cryotherapy. Arch Phys Med Rehabil. 2002;83:1501-1505.

34. Questions?