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Flashcards in PRAC ICE Deck (24):
1

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

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RICER

• Rest
• Ice
• Compression
• Elevation
• Referral

3

Physiological changes

1. Blood flow
2. Metabolism
3. Peripheral nervous system
4. Motor system
5. General effects

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1. 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

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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

6

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)

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2. 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

8

3. 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

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4. 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

10

5. 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

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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

12

other uses

• Ice massage for pressure sores
• Ice and stretching (in conjunction with Trigger point therapy – Travell
and Simmons)

13

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

14

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.

15

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˚

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2. 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

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3. Ice massage

• small areas eg tendon
• small circular motion
• can also be used to stimulate muscle contraction

18

4. Contrast baths

• Hot and cold water baths
• Hot = 40‐45°C, 3‐4 mins
• Cold = 15‐20°C, 1 min
• To reduce swelling, pain

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5. Spray and stretch

• Travel and Simmons 1993
• Myofascial techniques and trigger point therapy • Vapocoolant spray
• Passive sustained stretch

20

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

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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

22

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

23

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.

24

Heat or cold??

• Stage of inflammation
• Collagen extensibility
• Muscle spasm
• Muscle contraction
• Area to be treated
• Ease of use
• Patient preference