Cold Therapy Contraindications/Cryotherapy is defined as body cooling for therapeutic purposes. In sports and exercise medicine, cryotherapy has traditionally been applied using ice packs or cold-water immersion (CWI) baths. Recently, whole-body cryotherapy (WBC) has become a popular mode of cryotherapy. This involves exposure to extremely cold dry air (usually between −100°C and −140°C) in an environmentally controlled room for short periods of time (typically between 2 and 5 minutes). During these exposures, individuals wear minimal clothing, gloves, a woolen headband covering the ears, a nose and mouth mask, and dry shoes and socks to reduce the risk of cold-related injury. Although it was originally developed to treat chronic medical conditions, such as multiple sclerosis and rheumatoid arthritis,[rx]WBC is being increasingly employed by athletes. Its purported effects include decreased tissue temperature, reduction in inflammation, analgesia, and enhanced recovery following exercise.
Whole-body cryotherapy (WBC) involves short exposures to air temperatures below −100°C. WBC is increasingly accessible to athletes and is purported to enhance recovery after exercise and facilitate rehabilitation postinjury.
Cryotherapy, sometimes known as cold therapy, is the local or general use of low temperatures in medical therapy. Cryotherapy may be used to treat a variety of tissue lesions.[rx] The most prominent use of the term refers to the surgical treatment, specifically known as cryosurgery or cryoablation. Cryosurgery is the application of extremely low temperatures to destroy abnormal or diseased tissue and is used most commonly to treat skin conditions.
How Does the Procedure Work?
Cryotherapy uses nitrogen or argon gas to create extremely cold temperatures to destroy diseased tissue. To destroy diseased tissue located outside the body, liquid nitrogen is applied directly with a cotton swab or spray device. For tumors located below the skin surface and deep in the body, the physician will use image-guidance to insert one or more applicators, or cryoprobes, through the skin to the site of the diseased tissue and then deliver the liquid nitrogen or argon gas.
Living tissue, healthy or diseased, cannot withstand extremely cold conditions and will die from:
- ice formation in the fluid outside cells, which results in cellular dehydration.
- ice formation within the cell. At approximately -40°C (-40°F) or less, intracellular lethal-ice crystals begin to form and will destroy almost any cell.
- bursting from both swelling caused by ice expansion inside the cell or shrinking caused by water exiting the cell.
- loss of blood supply. Cells die when their blood supply is choked off by ice forming within small tumor blood vessels, causing clotting. Since the average blood-clotting time is approximately 10 minutes, the extreme cold is maintained for at least 10-15 minutes, if not longer, to assure that lethal-ice temperatures have been reached. Direct observation of the ablation temperature is possible with some apparatuses.
Because cryotherapy consists of a series of steps that lead to cell death, tumors are repeatedly frozen and thawed; typically, two or more freeze-thaw cycles are used.
Once the cells are destroyed, the white blood cells of the immune system work to clear out the dead tissue.
How is the Procedure Performed?
- Percutaneous image-guided procedures such as cryotherapy are most often performed by a specially trained interventional radiologist in an interventional radiology suite or occasionally in the operating room.
- This procedure is often done on an outpatient basis. However, some patients may require admission following the procedure. Please consult with your physician as to whether or not you will be admitted.
You will be positioned on the examining table.
If topical cryotherapy is performed, your physician will apply liquid nitrogen to the area with a cotton swab or spray device.
- For tumors deep inside the body that can be approached through the skin, your physician will perform a percutaneous procedure and insert thin, needle-size applicators or cryoprobes. You may be connected to monitors that track your heart rate, blood pressure, and pulse during the procedure.
- A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm so that sedative medication can be given intravenously. Moderate sedation may be used. As an alternative, you may receive general anesthesia. The area where the applicators or cryoprobe are to be inserted will be shaved, sterilized and covered with a sterile drape.
A very small skin incision is made at the site.
- Using imaging guidance, the physician will insert one or more applicators or cryoprobes through the skin to the site of the diseased tissue. Once the applicators or cryoprobe(s) are in place, the liquid nitrogen or argon gas is delivered. Aside from the cryoprobe(s), nothing else enters the body. An “ice ball” is created by a rapid decrease in the temperature at the tip of the probe. This causes all water in the area around the tip of the probe to freeze. Imaging is used to guide the placement of the applicators, and monitor the freezing process. The “ice ball” can be visualized using ultrasound, CT or MRI.
- Some tumors require multiple applicators to freeze completely. For prostate cancer, six to eight applicators are inserted through the perineum (the tissue between the rectum and the scrotum and penis) using ultrasound guidance.
- At the end of the procedure, the applicator(s) are removed and pressure will be applied to stop any bleeding. The opening in the skin is covered with a bandage. Typically, no sutures are needed.
- Your intravenous line will be removed.
The entire procedure is usually completed within one to three hours.
Cold Therapy Indications
It is unclear if whole body cryotherapy (WBC) has any effect on muscle soreness, or improves recovery, after exercise.[rx]
There is no evidence that whole body cooling effectively treats
- Pain management – Cold packs increase pain thresholds and thereby reduce pain. Cryotherapy can be used in both acute and chronic pain.
- Decrease muscle spasms – Cold therapy reduces the sensitivity of the muscle spindles and reduces pain. Thus, it helps to reduce muscle spasms.
- Reduce inflammation – Cold therapy slows the inflammatory response by reducing the release of inflammatory mediators.
- Edema management – Cold therapy reduces capillary permeability. As a result, cryotherapy helps to reduce edema as well as hemorrhage.
- Reduce spasticity – Muscle cooling has been found to reduce muscle stretch activity. Cryotherapy demyelinates nerves and reduces nerve conduction. This has been proven to reduce spasticity as well as fatigue in MS patients.
- Vasoconstriction – As cryotherapy lowers the tissue temperature, it acts as a vasoconstrictor. In the case of acute injury, this effect of cryotherapy along with elevation can stop bleeding along with easing pain.
- Relieve pregnancy back pain, muscle spasms, and cramps – Common pregnancy symptoms can be relieved using cryotherapy and is a safe alternative to medications.
- Reduce fever – Cryotherapy reduces fever by bringing the tissue temperature down. This has a significant impact on the physiological function of the body.
- Manage acute post-surgical conditions – In post-surgical conditions, ice packs can be used to manage pain, muscle spasm, and edema.
- Improve muscle fatigue – Athletes use ice packs during training or competitions. Cryotherapy chambers can also be used to recover from exercise-induced muscle injury or delayed onset of muscle soreness (DOMS).
- Induce temperature stress – Cryotherapy induces a short duration temperature stress to the body. The hormones released during stress — cortisol, adrenaline, and dopamine — increase the ability to withstand pain, fatigue, and hunger.
- Increase metabolism – After a session of cryotherapy, energy (calories) are used to reheat the body. It is hypothesized that during a three to the five-minute session, approximately 500 to 800 calories are burned.
- Cryotherapy can help with muscle pain, as well as some joint and muscle disorders, such as arthritis. It may also promote faster healing of athletic injuries.
- Cryotherapy is used in an effort to relieve muscle pain, sprains and swelling after soft tissue damage or surgery.
- Reducing anxiety and depression
- Pain relief and muscle healing
- Reduced inflammation
- Preventing dementia
- Alzheimer’s
- Preventing and treating cancer
- Improving symptoms of eczema
- Treating Migraine Headaches
- Fibromyalgia
- Migraines
- Rheumatoid arthritis
- Multiple sclerosis
- Stress,
- Anxiety
- Chronic pain as its proponents claim.[rx]
- Cancer
- Diabetes
- Depression
- Dementia and arthritis.
Cold Therapy Contraindications
Cold therapy, especially whole body cryotherapy, should be avoided in the following cases. Currently accepted contraindications for WBC include
- Any respiratory illness
- A history of heart attack in the past six months
- High blood pressure
- Unstable angina pectoris
- Cardiovascular disease or arrhythmias
- Circulatory disorders like peripheral arterial or venous disease (DVT)
- Anemia tumors
- History of stroke or cerebral hemorrhage
- History of seizures
- Raynaud’s syndrome
- Bleeding disorders
- Acute or chronic kidney disease
- Metal implants or pacemakers
- Pediatric patients (younger than 18)
- cryoglobulinemia
- cold intolerance
- Raynaud disease
- hypothyroidism,
- acute respiratory system disorders
- cardiovascular system diseases (unstable angina pectoris, cardiac failure in III and IV stage according to NYHA),
- purulent-gangrenous cutaneous lesions
- sympathetic nervous system neuropathies
- local blood flow disorders
- cachexia, and hypothermia, as well as claustrophobia and mental disorders hindering cooperation with patients during the treatment.
Cryotherapy Side Effects
There are a few side effects of cryotherapy treatments that therapists should note:
- While cryotherapy can reduce unwanted pain and nerve irritation, it sometimes can leave the tissue affected with unusual sensations, such as numbness or tingling.
- Cryotherapy can cause redness and irritation of the skin. But, these effects are generally temporary.
- If a localized cold pack or ice is left on the skin too long, it can cause integumentary damage (including frostbite in extreme cases). Therefore, localized cold therapy should never be applied longer than 30 minutes, and the skin integrity should be monitored during treatment.
- Whole body cryotherapy should not exceed five minutes (typical treatment sessions are two to three minutes). Whole body cryotherapy causes decreased heart rate, increased blood pressure, and lowered respiration. The patient’s vital signs and disposition should be monitored before, during, and after treatment. Oxygen levels inside the chamber should also be checked.
- The patient should ensure that all clothing and skin are completely dry when stepping into a cryotherapy chamber. Also, metal or jewelry should be removed. Last, sensitive body parts should be covered with a facemask, ear muffs, gloves, and socks or slippers. The burning of the skin or frostbite can occur when a patient does not follow proper protocol when entering a cryotherapy chamber.
WBC Has Proven to Injure the Skin
While the benefits of using WBC to treat sore muscles and diseases remain unproven, there’s evidence that the extreme cold can injure your skin.
Reported skin injuries due to WBC include:
- Frostbite
- A frozen limb
- Rashes
Frostbite
- This is the most common skin injury. American sprinter and 2004 Olympic champion Justin Gatlin developed frostbite on both feet during a WBC session, according to ESPN1. He’s not the only one. Researchers in Finland reported that 16% of the participants in a WBC research study developed mild frostbite. Frostbite occurs when your skin (and sometimes the tissue beneath your skin) freezes. This can lead to permanent tissue damage.
Frozen Limb
- While trying WBC for the first time, one woman finished her 3-minute session with a frozen arm, according to the Dallas Observer. As her arm thawed, she developed painful swelling, blisters, and third-degree burns2. This is a type of severe frostbite.
Rash (aka cold panniculitis)
- After having 8 WBC sessions within 2 weeks at a local gym, a 47-year-old man developed a rash. It started on his lower legs and spread to his thighs, belly, and arms. As the rash spread, it became somewhat itchy and painful.
Feeling very concerned, he saw a dermatologist and was diagnosed with cold panniculitis (pah-nick-you-lie-tis). This occurs when cold injuries the deepest layer of skin — the fatty tissue.
People who develop cold panniculitis often have a rash of:
- Tiny, hard bumps
- Raised and scaly patches
- Deep lumps in their skin
To get rid of this rash, you must stop injuring your skin. This allows the skin to heal on its own. When this man stopped WBC, it took several weeks for his skin to heal.
As the rash fades, some people see darker (or lighter) patches of skin where the rash once was. These patches can last for months before clearing.
Benefits
- When an open surgical approach is taken, the recovery time following cryosurgery of kidney or liver tumors may be less than for open, surgical removal of the tumor.
- For percutaneous cryotherapy, the patient may stay overnight or be released several hours after the procedure. Overnight stays for pain control are usually not needed.
- Percutaneous cryotherapy is less traumatic than open surgery since only a small incision is needed to pass the probe through the skin, which limits damage to healthy tissue. Consequently, percutaneous cryotherapy is less costly and results in fewer side effects than open surgery. A patient usually can resume activities of daily living 24 hours after the procedure, if not sooner. However, caution about heavy lifting may extend for several days after abdominal treatment.
- For treatment of fibroadenomas, cryotherapy causes minimal scar tissue and no apparent post-treatment calcifications.
Risks Factors
- Like any percutaneous procedure, bleeding may result—both from the puncture and the freezing of tissues such as the liver, kidney or lung.
- Damage to normal structures may occur. During liver cryotherapy, the bile ducts may be injured. During kidney cryotherapy, the ureter or collecting system may be damaged. The rectum may be damaged during prostate cryotherapy. Any treatment of the abdomen may result in damage to the bowel and cause a hole in the bowel, which may release bowel contents into the abdomen that can lead to potentially life-threatening infection.
- If freezing occurs near the diaphragm, fluid can accumulate in the space around the lungs.
- If the procedure is in or near the lung, the lung may collapse.
- Nerve damage may result. Completely frozen nerves can cause motor weakness or numbness in the area supplied by the nerves.
- Complications related to medications, including anesthesia, administered during the procedure may occur.
- Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant.
- This procedure may involve exposure to x-rays. However, radiation risk is not a major concern when compared to the benefits of the procedure.
Specific possible complications related to the cryotherapy of prostate cancer
- Permanent impotence since nerves controlling sexual potency is commonly involved in the freezing process. However, nerves can regenerate, resolving the problem in some patients.
- While the patient is under anesthesia, a bladder tube is positioned to drain urine until the swelling of the bladder neck—as a result of the procedure—resolves.
- May cause urethral sloughing; that is, blocking of the urine stream with dead tissue. Sloughing is reduced by keeping the urethra warm with sterile water circulating continuously through a catheter placed in the urethra during the procedure.
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