Recovery and provide the athlete with optimal health-care management.

Thermotherapy and cryotherapy are only two of the tools available to assist in the well-being and reconditioning of the injured athlete. CRYOTHERAPY TECHNIQUES Cryotherapy in the use of cold in the treatment of acute trauma and subacute injury and for the decrease of discomfort after athletic reconditioning and rehabilitation. Tools of cryotherapy include ice pack , cold whirlpool, ice whirlpool, ice massage commercial chemical cold spray, and contrast baths. Application of cryotherapy produces a three-to four-stage sensation. First there is an uncomfortable sensation of cold followed by stinging, then a burning or aching feeling, and finally numbness. Each stage is related to the nerve endings as they temporarily cease to function as a result of decreased blood flow. The time required for this sequences varies, but several authors indicate that it occurs within 5 to 15 minutes. After 12 to 15 minutes the hunting response is sometimes demonstrated with intense cold (10C[50F]). Thus a minimum of 15 minutes is necessary to achieve extreme analgesic effects. Application of ice is safe, simple, and inexpensive. Cryotherapy is contraindicated in patients with cold allergies ( hives, joint pain, nausea ), Raynauds phenomenon (arterial spasm), and some rheumatoid conditions. Depth of penetration depends of the amount of cold and the leght of the treatment time because the body is well-equipped to maintain skin and subcutaneous tissue viability through the capillary bed by reflex vasodilatation of up to 4 times normal blood flow. The body has the ability to decrease blood flow to the body segment that is supposedly losing too much body heat by shunting the blood flow. Depth of penetration is also related to intensity and duration of cold application and the circulatory respone to the body segment exposed. If the person has normal circulatory responses, frostbite should not be a concern. Even so, caution should be exercised when applying intese cold directly to the skin. If deeper penetration is desired, ice therapy is most effective using ice towel, ice packs, ice massage, and ice whirlpools. Patients should be advised of the four stages cryotherapya and the discomfort they will experience. The sports therapist should explain this sequence and advise the athlete of the expected outcome, wich may include a rapid decrease in pain.

Ice Massage Ice massage can be applied by the sports therapist or the athlete if the athlete can reach the area of application to administer self-treatment. It is best for the first three treatments to be administered by the sports therapist to give the athlete the full benefit of the treatment. When positioning the athletes body segmen to be treated, it should be relaxed and the athlete should made be comfortable. Appropriate seating and positioning should be taken into consideration

with the application of ice. Administration must be thorough to get maximal treatment. Ice massage is perhaps best indicated in conditions in which some type of stretching activity is to be used. EQUIPMENT NEEDED A. Styrofoam cups. A regular 6-to8-ounce Styrofoam cup should be filled with water and placed in the freezer. After it is frozen, all the Styrofoam on the sides should be removed down to 1 inch from the bottom. This device is preffered because it has handle with which to hold the block of ice. B. Popsicle ice cups are filled with water, and a wooden popsicle stick (tongue blade) is placed in each cup. The cups are then placed in the freezer. After it is frozen the paper cup is torn of. A block of ice on a stick is now ready to be used for massage purposes. C. Paper cups. Same techniques as the Styrofoam cups, exept toweling may be needed to insulate the sports therapists hand holding the paper cup. D. Towels. Thes are used for positioning and absorbing the melting water in the area of the ice massage application. TREATMENT A. Athlete position. Sidelying, prone, supine, hooklying, or sitting, depending on the area to be treated. B. Self-treatment. Used when athletes can comfortably reach the area to be treated by themselves. C. Circular motion. Application of ice massage in a circular pattern with each seceding stroke covering half the previous stroke. D. Longitudinal strokes. Application of ice massage in a longitudinal motion with each stroke overlapping half the previous stroke. E. Peripheral coverage. Ice should be applied for 15 t0 20 minutes; consistent patterning of circular and longitudinal strokes includes the sequence described in the clinical uses section. PHYSIOLOGIC RESPONSES A. Cold progression proceeds through the four stage : cold, stinging, burning, and numbness. B. Reddening of the skin (erythema) occurs as a result of blanching or lack of blood in the capillary bed. A common example occurs when one works outside in the cold without

gloves or appropriate footwear and returns inside to find the toes beet-red. The body is attempting to pool blood in the area to prevent further temperature loss. C. Ice applications of 5 to 15 minutes and greater than 10C (50F) will not stimulate the hunting response and do not stimulate the reflex vasodilation that creates the bodys own physically induced heat or increased blood flow. CONSIDERATION A. The time necessary for the surface area to be numbed will deepend on the body area to be massaged. Approximate time will depend on how fast the ice melts and what thermopane develops beetwen the skin and ice massage. B. Athlete comfort should be considered at all times. C. If adequate circulation is present, frostbite should not be a concern. However, if the athlete has diabetes, the extremities, especially the toes, may require reduced temperature and adjustment of the intensity and duration of the cold.

APPLICATION After the type of cold applicator for ice massage is selected, the athlete should be positioned comfortably and clothing should be removed from the area to be treated. The area should be set up before positioning the athlete. Remove the top two thirds of paper from the ice-filled paper or Styrofoam cup, leaving 1 inch on the bottom of the cup as a handle for the therapist or athlete to use as a handgrip. The therapist should smooth the rough of the ice cup by gently rubbing along the edges. Ice should be applied to the athletes exposed skin in circular or longitudinal strokes, with each stroke overlapping the previous stroke. The application should be continued until the athlete goes through the cold progression sequence of cold, stinging, burning or aching, and numbness. Once the skin is numb to fine touch, ice application can be terminated. The cold progression is the response of the sensory nerve fibers in the skin. The difference beetwen cold and burning is primarily between the dropping out (sensory deficit) of the cold and warm nerve endings. Standard treatments allow the athlete to place cold applications every other 20 minutes, thus facilitating the hunting response. Some thermobarrier is developed during the ice massage in the layer of water directly on the skin, but this allows the ice cup to move smoothly over the skin. The time from application to numbing of the body segment depends on the size of the segment, but progression to numbing should be around 7 to 10 minutes. Commercial (Cold) Hydrocollator Packs Cold hydrocollator packs (Figure 9-3) are indicated in any acute injury to musculoskeletal structure.

EQUIPMENT NEEDED A. Hydrocollator cold pack. This must be cooled to 8F (-15C); a 120V cycle is commercially available. It needs plastic lines or protective toweling for placement on a body segment. Petroleum distillate gel is the substance contained in the plastic pouch design. B. Moist cold towels. Towels may be immersed in ice water and molded to the skin surface, or they can be packed in ice and allowed to remain in place. The commercial cold pack should be placed on top of a moist towel. C. Plastic bag. The hydrocollator should be placed in the bag. Air should be removed from the bag. The plastic bag may then be molded around the body segment. D. Dry towel. To prevent the cold hydrocollator from losing heat rapidly, the towel is used as a covering to insulate the cold pack. TREATMENT A. Athlete position. Sidelying, prone, supine, hooklying, or sitting, depending on the area to be treated. B. The patient must remain still during the treatment to maintain appropriate positioning of the cold pack. C. Cold pack must be molded onto the skin. D. The pack should be covered with a towel to limit loss of cold. E. A timer should be set, or time should otherwise be noted. F. Treatment time should be 20 minutes.

PHYSIOLOGIC RESPONSES A. Cold progression proceeds through the four stages. B. Erythema occurs CONSIDERATIONS A. Body area should be covered to prevent unnecessary exposure. B. The physiologic response to cold treatment is immediate. C. Athlete comfort should be considered at all times.

D. Frostbite should not be a concern unless circulation is inadequate APPLICATIONS The athlete should be positioned with treatment area exposed and towel draped to protect clothing. The commercial cold pack should be placed against wet toweling to enhance transfer of cold to the body segment. If the injury is acute or subacute, the body segment should be elevated to reduced gravity-dependent swelling. Pack the cold pack around the joint in a manner designed to remove all air and ensure placement directly against wet toweling. Cold progression will be the same as with ice massage but not as quick because of the toweling beetwen the skin and cold pack. General treatment time required for numbing is about 20 minutes. The importance of a comfortable, properly positioned athlete is evident. Checking the sensory area after application is important. Again, frostbite should not be a concern if circulation is intact. If swelling is a concern, a wet compression (elastic) wrap could be applied under the cold pack. A sequence of 20 minutes on and 20 minutes off should be repeated for 2 hours; the same sequence can be used in home treatment. Elevation is a key adjunct therapy during the sleeping hours. Ice Pack Like cold hydrocollator packs, ice packs (Figure 9-4) are indicated in acute stages of injury, as well as for prevention of additional swelling after exercise of the injured part. EQUIPMENT NEEDED A. Small plastic bags. Vegetable or bread bags may be used. B. Ice flaker machine. Flaked or crushed ice is is easier to mold than cubed ice. C. Moist towels. These are used to facilitate cold transmission and should be placed directly on the skin D. Elastic bandaging. Bandaging holds the plastic ice pack in place and applies compression. The body segment may be elevated E. Salt solution. This is used to increase melting temperature. Melting ice has more thermal energy thn stable ice and is therefore colder. TREATMENT A. Athlete position. Position depends on the part to be treated. B. The patient must remain still during treatment. C. Pack must be placed on skin. D. Pack should be secured in place with toweling or elastic bandage.

E. Pack should be covered with towel to limit cold loss. F. A timer should be set, or time should otherwise be noted. G. Treatment time should be 20 minutes. PHYSIOLOGIC RESONSES A. Cold progression proceeds through the four stages B. Erythema occurs.