Cryotherapy

Review of physiological effects and clinical application1

Jeffrey J. Ciolek, P.T., A.T., C. Cryotherapy, the therapeutic use of cold in the management of
injuries and painful conditions, can be a valuable technique for
the medical practitioner. The physiologic effects of cold are vaso-
constriction, which helps to decrease swelling and inflammation;
decreased tissue hypoxia; decreased pain; and decreased muscle
spasm. Integrating cold in both the acute and rehabilitation stage
can promote quick and effective results. Combining cold with
exercise (cryokinetics) has significant clinical implications for the
treatment of many musculoskeletal problems, athletic injuries, and
inflammatory conditions such as tendonitis, bursitis, and arthritis.
Application of ice provides a safe, convenient, and inexpensive
method of treatment for the patient, especially in the home setting.
Index term: Cryotherapy
Cleve Clin Q 5 2 : 1 9 3 - 2 0 1 , Summer 1985

T h e therapeutic use of cold in the management of acute

and chronic musculoskeletal pain is not new. The use of
ice has traditionally been accepted as the standard method
for treating common sprains and strains immediately fol-
lowing an injury. Basic first aid texts or emergency room
instructions would often advise the use of ice for initially
1
24 hours, followed by heat. 1 A more effective treatment
Department of Physical Therapy and Section of regimen might use cold therapy in later phases of the injury
Sports Medicine, T h e Cleveland Clinic Foundation.
Submitted for publication Nov 1984; accepted Apr cycle, during the rehabilitation phase, and even in the
1985. lp chronic stage of injury. 2-4
Cryotherapy can be defined as the use of some modality
0009-8787/85/02/0193/09/$3.25/0
such as ice for the purpose of lowering temperature to
Copyright < 1985, The Cleveland Clinic Foun- attain therapeutic effects. T h e purpose of the review of
dation literature is to provide the reader with a thorough under-
193

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194 Cleveland Clinic Quarterly Vol. 52, No. 2

standing of the physiologic effects of cold, to tional vasoconstriction is achieved because of

clarify practical methods of application of various slower blood flow into the injured area.
cold therapy techniques, and to demonstrate in- This initial response of vasoconstriction pro-
tegration of cryotherapy into effective treatment duced by cold application is considered to be the
planning by the medical practitioner. principal mechanism to reduce swelling and
When an injury occurs in a sports setting, bleeding after trauma and to decrease edema in
vigorous attempts are often made to return ath- inflammatory reactions. 12
letes to competition as quickly and safely as pos- Knight 5 suggested that controlling and reduc-
sible. Athletic trainers, sports therapists, and phy- ing the hematoma formation in an injury is vitally
sicians working in sports medicine settings have important for adequate progression of the heal-
realized the successful potential of ice as an effec- ing process. Control of excessive swelling, hem-
tive treatment modality for many years. Clinical orrhage, and exudate formation decreases the
and empirical evidence appears to demonstrate
initial severity of the injury, promoting successful
that early and frequent cold application during
rehabilitation.
the acute and rehabilitative phases can result in
more successful management of the injury. Sim- Garrick 13 stated that what one does during the
ilar techniques and application of cryotherapy first 24 hours of treatment may have as much to
with the nonathletic patient can also be applied. do with healing six months later as anything else
Ice can be a valuable therapeutic agent for the that is done.
treatment of arthritis, low back pain, bursitis, Guyton 14 stated that when cold was applied
common musculoskeletal problems, and other directly to the skin the vessels progressively con-
inflammatory conditions. strict and are lowered to a temperature of about
15 °C, at which point they reach their maximum
Physiological effects of cold degree of constriction. At temperatures below 15
°C, the vessels appear to dilate. This dilation is a
The physiological effects of cold most com- direct local effect of the cold on the vessels them-
monly noted are:
selves, and is thought to be a paralysis of contrac-
1. Vasoconstriction to decrease swelling and
tile mechanism of the vessel wall or block of nerve
inflammation,
impulses coming to the vessels. This vasodilation,
2. Decreased tissue hypoxia,
which occurs in severe cold, can protect against
3. Decreased pain, and
freezing, especially of the hands and ears.
4. Decreased muscle spasm.
Lewis15 first noted that when subjects removed
Vasoconstriction their fingers from ice water, skin temperature
rose above preimmersion level. A similar type of
Vasoconstriction is the initial response of the reflex vasodilation appears to occur on the facial
cells to the application of ice.5"9 Cold elicits an region. During Lewis's study, a thermocouple
immediate and direct constriction of surface
was attached to the finger to measure tempera-
blood vessels through an axon reflex arc that is a
tures before and after a period of immersion.
projection of the peripheral autonomic system
controlling sympathetic vasoconstriction. 10 Vaso- Results showed an initial increase postimmersion
constriction also occurs through reflexive action and then fluctuations in temperature caused by
via the spinal reflexes. 6 Cooled venous blood alternating vasodilation and vasoconstriction.
returning to the general circulation activates This characteristic feature of vasodilation caused
the posterior hypothalamus to further increase by cold has become known as the "Lewis hunting
vasoconstriction. reaction."
Cold is thought to be therapeutically effective Decreased tissue hypoxia
because it decreases vascular permeability, which
draws the cell wall together. 5 T h e decrease in Ice markedly decreases tissue hypoxia. Knight 5
permeability is beneficial because it reduces the explained that cold induces a temporary hiber-
amount of fluid that leaks into the extracellular nation state of the tissue and therefore decreases
spaces. Edwards and Burton 11 noted that cold the possibility of extensive secondary damage.
increases blood viscosity, which also helps to de- Following an injury, tissue disruption reduces
crease blood flow into the injured area. Addi- available oxygen supply, and therefore the met-

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Summer 1985 Cryotherapy 195

abolic needs of the uninjured tissue may not be even greater drop in nerve conduction velocity
met. Secondary tissue hypoxia often develops. when the ice pack was applied directly to the
Ice application decreases the metabolic demands elbow region. This appeared to indicate that icing
of the area and subsequently decreases the actual where the nerve is more superficial produced a
need for oxygen. It has been suggested that the greater and more rapid reduction in nerve con-
rate of chemical reaction is reduced by one half duction velocity.
with 10 °C drop in temperature. 8 Abramson et al20 reported that changes in
The protective effect of ice is critical in the nerve conduction velocity are thought to be
early management of injuries, as often a simple caused by a fall in tissue temperature adjacent to
contusion or a sprain is aggravated because of the nerve rather than to a marked change in the
secondary complications of bleeding and exudate blood flow to the area. Dejong et al 16 concluded
formation. that changes in conduction velocity during cool-
ing and rewarming can be due to thermal effects
on the nerve fiber membrane. Bugaj 21 analyzed
Decreased pain
the effectiveness of the ice massage technique in
Decrease in pain is frequently accomplished reducing the localized skin temperature and
through a direct and indirect mechanism. Several maintaining analgesia. His study demonstrated
studies have demonstrated that ice may cause a that an analgesic effect began when localized skin
temporary decrease in nerve conduction velocity. temperature was lowered to approximately 13.6
Clarke et al9 noted that cooling below 20 °C °C. Analgesia began one minute and 45 seconds
caused significant reduction in the production of after ice application and terminated two minutes
acetylcholine along cooled nerve, which varied and 57 seconds following removal of the cold
according to the size of the fiber. This seemed to agent.
produce an asychrony of impulses and therefore Stimulation of sensory fibers may relieve pain
decreased pain. through a bombardment mechanism similar to
Olson and Stravino 8 suggested that cold may Melzack's gate control theory of pain. 22 An indi-
produce a temporary limited anesthesia due to rect decrease of pain occurs through alteration
decreased nerve conduction velocity or to com- of muscle spasm, spasticity, and control of swell-
petitive inhibition within the central nervous sys- ing. T h e pain-spasm cycle can be arrested
tem. Dejong et al16 similarly demonstrated an through the use of cold.
effect on nerve conduction velocity caused by
cold. He showed a linear association between
conduction velocity and temperature above Decreased muscle spasm
25 °C. Haines 23 revealed that local cryotherapy can
Dejesus et al17 reported that cold caused a produce a temporary damping of spasticity, prob-
decrease in velocity of conduction in nerve fibers, ably by decreasing responsiveness of muscle spin-
but suggested that certain classes of fibers are dles to stretch. Eldred et al 24 demonstrated that
more sensitive to cold than others. T h e conduc- a cooler muscle had a lower rate of firing from
tion velocity of large group-A fibers decreased the afferents arising from flower-spray annulo-
most rapidly with cold, followed by group-B and spiral endings. Changes in discharge of the mus-
group-C fibers. cle spindle may result from the extrafusal muscle,
Lehmann and DeLateur 12 reported that the the intrafusal fibers, or the sensory endings.
sensitivity of nerve fibers to cold appears to de- Hartviksen 25 reported a generalized decrease
pend largely upon myelination and upon fiber in spasticity in the gastrocnemius in patients
diameter. Douglas and Malcolm 18 in experiments (quadriplegics, paraplegics, hemiplegics) treated
with cats studied the differential effect of cold on with cold therapy. T h e most significant reduction
fibers, and finally unmedullated fibers. Specifi- in spasticity occurred while the ice packs were
cally, they found that small y efferent fibers were applied; however, changes were noted for several
more sensitive to cold than larger a efferent hours afterwards.
fibers. Lee et al19 noted a reduction in nerve Knutsson 26 studied the effect of topical cryo-
conduction velocity of 11.6% in the ulnar nerve therapy in spasticity by analyzing the resistance
when an ice pack was applied over the flexor to passive movements, clonus, and maximal con-
carpi ulnaris muscle. They then demonstrated an traction forces in the spastic muscles. This study

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196 Cleveland Clinic Quarterly Vol. 52, No. 2

concluded that cold may reduce activity in the serious chemical burns. Ice can easily be stored
spastic muscle and enhance the contraction of the in a cooler and therefore be accessible for picnics,
antagonist muscle. Knutsson and Mattsson 27 travel, or sports events.
showed a mean (34%) amplitude decrease in ten- When applying ice, a wet elastic bandage
don jerks following a 20-minute cooling period should be applied to the injured area. This pro-
of the triceps surae muscle. They concluded that vides the additional benefit of uniform pressure
both peripheral and central excitability changes to the area, and wetting the wrap facilitates pen-
had potential effects on the muscle spindle. etration of cold. A dry wrap or towel under the
Hedenberg 28 functionally tested the upper ex- ice decreases cold penetration. T o gain additional
tremity of 24 spastic hemiplegics before and after compression and uniformity of cooling, another
immersion in cold water. A significant improve- wrap can be used to secure the ice pack. If an
ment in functional capacity was noted after the elastic wrap is not available, the ice bag may be
cooling, having positive implications for better placed directly on the skin.
performance throughout the active hours of the Twenty-minute periods of application of ice
day. packs at one-hour intervals is recommended for
T h e general temporary change in muscle spin- optimal treatment benefit and tissue safety. The
dle activity may be additionally responsible for one-hour interval permits the tissue temperature
the overall decrease in muscle spasm often asso- to reach pretreatment level.
ciated with many painful conditions. Griffen and Compression and elevation should be contin-
Karselis29 noted that "when pain is present, there ued between ice applications. T h e most successful
is often concomitant local circulatory impair- management of an acute injury requires repeated
ment. One known cause of such impairment is applications of cold. If possible, the body segment
skeletal muscle spasm, which can significantly of the injured area should be completely sur-
limit venous return. Such flow deficit can give rounded with ice to provide uniform cooling,
use to additional pain because the deficit leads to e.g., an ice pack on both sides or front and back
inadequate local removal of metabolic waste of the knee.
products."
Ice massage
Methods of application of cold therapy
Ice massage, the second method of cryotherapy
Three of the most common methods of apply- is often used after the acute stage of injury;
ing cold are ice packs, ice massage, and ice im- however, it may safely be initiated immediately
mersion. Each appears to be effective at different following an injury. Water frozen in a paper or
phases in the program, on different problems, Styrofoam cup is gently massaged or rubbed onto
and in different regions of the body. Successful the injured area, with circular or longitudinal
results can be enhanced through selection of the strokes. This technique appears to work best over
most appropriate method. a muscular area as the quadriceps, gastrocnemius,
or low back; however, it can be used effectively
Ice pack over a joint surface like the knee. Treatment in
The treatment of choice, in the acute state of this case, is generally 10 minutes, but can be
injury, is some form of ice pack. T h e familiar extended for as long as 20 minutes.
mnemonic ICE has traditionally been used to The practitioner should understand and care-
refer to Ice, Compression, and Elevation. All fully explain to the patient the sensations that
three components must be incorporated to will be experienced with this method of treat-
achieve optimal results. One of the simplest but ment. T h e initial response is a feeling of cold,
most effective methods is the use of cubed or followed by a burning sensation, and then, often,
crushed ice in a plastic bag. This is usually readily pain. This frequently makes the beginning phase
available and therefore self-treatment can easily of the treatment difficult to tolerate. It should be
be administered. T h e plastic bag method pro- pointed out that this is only a temporary response
vides quick and optimal cooling, which can be and will be followed by numbness or mild anes-
uniformly maintained throughout the treatment. thesia. Clinical evidence suggests that the patient
Chemical ice packs should be avoided. On many will experience these four stages of cold, burning,
occasions, they have broken open and caused pain, and numbness much more quickly with ice

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Summer 1985 Cryotherapy 197

massage than with an ice pack. 21 T h e anesthesia results of their study showed that the reduction
phase becomes an integral part of the rehabilita- in intramuscular temperature varied from 0.4 to
tion program. 1.9 °C (mean, + 1.2 °C) when recorded at 4.3
Lowdon and Moore 30 demonstrated that ice cm below the skin surface. Johnson et al 33 con-
massage produced a rapid decrease in intramus- cluded that intramuscular temperature of the
cular temperature of 15.9 °C in five minutes. He lower leg decreased 12.0 °C by submersion in
related, however, that subcutaneous tissue thick- cold-water bath of 10 °C. Reduction of intra-
ness and limb circumference should be taken into muscular temperature by direct application of
account when determining treatment time for ice cold was directly related to the percentage of
massage. This method of treatment is convenient body fat of the subject. Also, intramuscular tem-
and can achieve valuable therapeutic effects perature of the lower leg, after 30 minutes of
quickly. submersion in 10 ° C water, remained lower than
presubmersion level up to four hours when the
Ice immersion subject did not contract those muscles.
Bierman and Friedlander 34 studied the pene-
Ice immersion, the third method of cryother- tration of cold by placing an ice bag on each side
apy, is most frequently used for treatment of the of the human gastrocnemius for a period of two
distal extremities such as the hands or feet. T h e
hours. During that time, skin temperature and
patient can fill a tub, bucket, wastebasket, or
the muscle temperature 5.08 cm below the skin
whirlpool with ice and water to reach a water
surface was recorded. Skin temperature dropped
temperature of 40 to 60 °C. T h e patient can
quickly upon application of cold and was main-
easily exercise or move the injured part while
immersed to help increase range of motion. Ice tained at approximately 6.1 °C whereas intra-
immersion has the advantages over the other muscular tissue did not begin to show a significant
methods when treating fingers or toes of com- drop in temperature for at least 30 minutes and
pletely enveloping the injured part. A disadvan- then only to levels slightly below 32.3 °C.
tage of ice immersion is that the extremity is in a Waylonis studied the effect of ice massage to
dependent position. However, it can be elevated the thigh and calf for five to ten minutes. Skin
immediately following the treatment if necessary. temperatures dropped as much as 19.2 °C, with
the smaller drops in deeper structures.
T h e initial pain associated with application of
ice is most evident with ice immersion. Clinical Thermal receptors for cold and warmth appear
impressions indicate that patients are able to to be simple unencapsulated nerve endings or
adapt to this initial painful response. It often nerve nets found profusely throughout the
appears with frequent applications of long-term skin.7'14 T h e sensitivity of nerve fibers to cold
treatment that an increased tolerance is estab- appears to depend largely upon myelination and
lished. Glaser and Whittow's study 31 showed that fiber diameter. Small medullated fibers appear
following repeated ice immersions, a rise in blood to be affected first.12 Lehmann and DeLateur 12
pressure and heart rate during localized cooling state that pain is relieved by elevating the pain
was significantly diminished, and pain from cool- threshold as a direct effect of temperature reduc-
ing was abolished. They concluded that localized tion on nerve fibers and receptors.
adaptation to cold is due to habituation, which Cold receptors become highly sensitive when
plays an important part in acclimatization. stimulated by a sudden fall in temperature. This
Several studies evaluated temperature changes immediate occurrence fades rapidly during the
superficially and intramuscularly. Abramson et first minute, and progressively more slowly dur-
al noted that tissue temperature fell rapidly ing the next half hour. It also appears that cold
with the application of ice with the greatest effect receptors display a certain degree of adaptation
noted in the skin and the least in the muscle. In causing a change in frequency of discharge. 14
the later part of cooling, the fall in tissue temper- Guyton 14 reports that thermal receptors are
ature slowed and eventually plateaued despite stimulated by changes in metabolic rates. Tem-
continued cooling. Wolf and Basmajian 32 ana- perature alters the rate of intracellular chemical
lyzed the reduction in deep intramuscular tem- reaction about 2.3 times for each 10 °C change.
peratures when the skin overlying the left medial It is suggested that thermal detection results not
gastrocnemius was cooled for five minutes. T h e from direct physical stimulation, but instead from

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198 Cleveland Clinic Quarterly Vol. 52, No. 2

chemical stimulation of endings as modified by motion exercises with less difficulty. The patient
the temperature change. can still use pain as á guide for the exercise.
Integration of exercise with cryotherapy can
Clinical applications of cryotherapy often help prevent tissue tightness and adhesions.
T h e ice becomes a dynamic component because
Many authors have reported the clinical advan- it decreases pain and accompanying muscle spasm
tages of cryotherapy in the management of both in the injured area.
acute and chronic conditions. McMaster 4 stated that cold may decrease the
It is generally accepted that the primary ration- excitability of free nerve endings and peripheral
ale for cryotherapy in the acute stage is vasocon- nerve fibers, thus increasing the pain threshold.
striction and pain reduction. Following standard This may support the concept of utilizing cold
guidelines for applying ice packs, one might therapy in chronic conditions. This temporary
achieve better control of bleeding and swelling
reduction in pain appears to be effective in the
into the injured area. Rest of the injured area is
management of some arthritic conditions and
also of critical importance to protect the damaged
other common painful musculoskeletal disorders.
structures during the immediate phase of heal-
ing. Clinically, pain reduction following cryother-
apy appears to be greater than that following
Greater use of cryotherapy beyond treatment
superficial heat treatment, such as hot packs and
of acute injuries may be significantly helpful for
whirlpools. There may also be a long-lasting re-
the medical practitioner. Using cold as an effec-
duction in pain following the treatment.
tive rehabilitation tool is not commonly discussed
in the literature. However, integrating cold ther- Cryotherapy after activity can be effective in
apy into various phases of the rehabilitation pro- reducing postexercise pain. This can have valua-
gram can be an extremely valuable technique. ble implications for many individuals who expe-
T h e key goal during the healing and rehabilita- rience muscular or joint discomfort after recrea-
tion phase is to increase circulation to enhance tional activities. Arthritics often complain of pain
the healing process. Exercise becomes the most following prolonged weight bearing or with in-
important component at this stage in rehabilita- creased physical activity such as working in the
tion. garden. Prentice 38 used electromyographic analy-
sis to determine the effectiveness of heat or cold
T h e term cryokinetics can simply be defined as
the combination of cold and exercise. It is gen- and stretching for inducing relaxation in injured
erally felt that increasing blood flow speeds up muscles. He concluded that cold combined with
the removal of cellular debris from the injury site static stretching seemed superior to other forms
and increases delivery of nutrients to be used in of treatment in reducing postexercise discomfort.
rebuilding the damaged area. The cold and stretching appeared to suppress
Knight et al36 studied the effects of cryotherapy muscle spindle activity, which helps to decrease
on vasodilation. Their results suggest that cryo- muscle pain. T h e use of ice on a regular basis
therapy must be combined with exercise to effec- after activity or at the end of the day may reduce
tively achieve long-term vasodilation or increased pain and inflammation.
circulation benefits. Knight and Londeree 37 com- Cryotherapy for patients with frozen shoul-
pared blood flow in the ankle during the thera- ders, cervical myalgia, low back pain, and bursitis
peutic applications of heat, cold, and exercise. who complain of night pain may often provide
Their data suggest that exercise following cryo- the necessary initial relief to allow sleep.
therapy is most successful in increasing blood Knott and Barufaldi 39 demonstrated success in
flow. Cryotherapy appears to allow easy and treating whiplash injuries by combining cryother-
more comfortable active motion of painful joints. apy and a series of controlled isometric exercises.
Early mobilization of the injured area allows The study of Hocutt et al 40 assessed the recov-
quick return of full range of motion and resto- ery from ankle sprains showing that cryotherapy
ration of strength. started within 36 hours after the injury was sta-
A 10- to 15-minute icing period might be used tistically more effective than heat therapy for
before exercise. This should achieve significant complete and rapid recovery. Early initiation
anesthesia adjacent to the injured area, which of cryotherapy appeared to yield earlier recovery
might allow the patient to begin active range of from ankle sprains. Basur et al41 similarly found

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Summer 1985 Cryotherapy 199

that recovery from ankle sprains occurred earlier quently presented as classical cold urticaria. T h e
in the group treated with cryotherapy. second type is the result of the presence of cold
Hayden reported the success of cryokinetics hemolysins and agglutinins, primarily producing
in an early treatment program of 1,000 patients general symptoms such as malaise, chills, and
in a military setting who had common acute and fever with significant anemia. T h e third type is
painful muskuloskeletal conditions. He urged pa- the result of the presence of cryoglobulins, which
tient responsibility for treatment because of the in turn produce chills and fever and seriously
ease of compliance with cryotherapy. affect both vision and hearing to the point of
Grant 3 reported beneficial results of ice mas- blindness and deafness.
sage in more than 7,000 outpatients. Although The clinician should be aware of the possibility
his study did not include adequate control, the of these hypersensitivities especially in patients
magnitude of his population suggests credibility. with associated diseases such as lupus erythema-
He also used combined ice massage and exercise. tosus, atypical pneumonia, rheumatoid disease,
The study of Yackzan et al 43 pointed out that progressive symptomatic sclerosis, or multiple
ice massage alone was not effective in relieving myeloma.
delayed muscle soreness. However, clinical evi- Raynaud's phenomenon often associated with
dence may support the advantage of combining rheumatic conditions may preclude cold applica-
ice with exercise. tion. One should be especially careful when treat-
Cornelius and Jackson 44 indicated that cryo- ing the distal extremities because of the patho-
therapy and proprioceptive neuromuscular facil- logical increase in arterial tone and the potential
itation (PNF) is an effective method of increasing for closure of the digital arteries. 12
hip extensor flexibility. Additional precaution should be exerted for
The application of ice to acute and subacute those individuals with severe peripheral vascular
rheumatoid joints is supported by the work of disease with arterial insufficiency. T h e vasocon-
Harris and McCroskery. 45 They found that stricting effects of cold may be potentially harm-
destructive enzymes are more active at higher ful.4-12
temperatures. It would seem that cold applica- The practioner should also exhibit added care
tions could be extremely valuable for the rheu- for individuals with insensitive skin or unstable
matoid patient, especially in a flare-up stage. cardiac patients. 4 ' 12
Temporary relief of pain via cryotherapy may A frequent question is about the occurrence of
allow important range of motion exercises. 46-48 frostbite from ice treatment. Tissue damage from
The number of well-controlled studies com- frostbite is possible though rare if standard cry-
paring heat versus cold treatment of various mus- otherapy guidelines are followed. Prolonged ex-
culoskeletal problems are limited. However, posure to cold, water, and low environmental
there appears to be valid justification for incor- temperature may increase the risk of frostbite.
porating cryotherapy into the treatment of Extreme caution should however be exercised in
chronic problems and throughout all phases of using a vapocoolant such as ethyl chloride since
rehabilitation. Potential increases in the inflam- rapid cooling of the skin occurs and possible
matory reaction could occur if heat is applied too freezing of the tissue might result. 12
early in the postinjury phase. Also, heat applied Proper use of cold is important to eliminate
to an injured joint or muscular area after exercise potential problems due to extreme cooling. One
or activity may actually increase swelling. Ice case report of cold-induced nerve palsy was re-
might have some advantages over heat because ported following a two-hour application of ice to
of this inflammatory factor. the knee of an injured high school athlete. 50 This
type of adverse reaction should be prevented by
Contraindications limiting the treatment time to 20 minutes.
The occurrence of severe adverse reactions to
cold are rare; however, several studies have re- Conclusions
ported contraindications and precautions. Juhlin The effectiveness of cryotherapy in the treat-
and Shelley49 classified three types of cold hyper- ment of acute injuries appears to be well accepted
sensitivity. T h e first type is the result of release in the clinical setting. Incorporating cryotherapy
of histamine or histaminelike substances, fre- into other phases of rehabilitation can be sup-

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200 Cleveland Clinic Quarterly Vol. 52, No. 2

ported because of the natural physiologic re- 16. D e j o n g RH, Hershey W N , Wagman IH. Nerve conduction
velocity during hypothermia in man. Anesthesiology 1966;
sponse from ice. Decreased swelling and inflam-
27:6, 805.
mation, decreased pain, and decreased muscle 17. Dejesus PV, Hausmanowa-Petrusewicz I, Barchi RL. T h e
spasm, which occur with cryotherapy clearly effect of cold on nerve conduction of human slow and fast
should help to rationalize its value, in the treat- nerve fibers. Neurology 1973; 2 3 : 1 1 8 2 - 1 1 8 9 .
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be a safe, convenient, and successful mode of Levin M. Effect o f tissue temperature and blood flow on
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1088.
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ice massage on localized skin. Phys T h e r 1975; 5 5 : 1 1 - 1 9 .
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Iorio for her patience in typing this manuscript. 23. Haines J. A survey of recent developments in cold therapy.
Physiotherapy 1967; 5 3 : 2 2 2 - 2 2 9 .
Department of Physical Therapy 24. Eldred E, Lindsley DF, Buchwald JS. T h e effect of cooling
Section of Sports Medicine on mammalian muscle spindles. Exp Neurol 1960; 2 : 1 4 4 -
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9500 Euclid Ave. 25. Hartviksen K. Ice therapy in spasticity. Acta Neurol Scand
Cleveland OH 44106 1962; 38(suppl 3 ) : 7 9 - 8 4 .
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