Peripheral Blood Flow

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

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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

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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

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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

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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

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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.

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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.

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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

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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

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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)

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Instrumentation

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

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Procedures

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

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Protocol

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

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

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Results

• A significant interaction between treatment and
  time F(2,10) 0.923, p lt 0.0001 and position
  and time F(2,10) 0.923, p lt 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)

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TABLE 1. Temperature by condition (oC) pre-test,
initial post-test, 15 minutes post-test (Mean
SD)
VARIABLES Mean Standard Deviation
Pre-Test No Ice
No-Elevation 26.51 1.04
Elevation 27.11 1.36
Treadmill 26.61 1.88

Initial Post-Test No Ice
No-Elevation 27.35 1.17
Elevation 27.19 1.42
Treadmill 27.10 1.59

15 Minutes Post-Test No Ice
No-Elevation 27.05 1.32
Elevation 26.93 1.35
Treadmill 27.42 1.68

Pre-Test Ice
No-Elevation 26.82 1.66
Elevation 26.65 1.74
Treadmill 27.03 1.60

Initial Post-Test Ice
No-Elevation 14.78 2.53
Elevation 13.29 2.07
Treadmill 12.65 1.02

15 Minutes Post-Test Ice
No-Elevation 22.68 1.59
Elevation 22.09 1.52
Treadmill 23.37 1.66
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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)
VARIABLE PRE Temp (Co) 95 CI POST Temp (Co) 95 CI ES
No-Elevation No Ice 26.51 1.04 25.92 to 27.09 27.05 1.32 26.30 to 27.79 0.519
Elevation No Ice 27.11 1.36 26.34 to 27.88 26.93 1.35 26.17 to 27.69 0.132
Treadmill No Ice 26.61 1.88 25.55 to 27.67 27.42 1.68 26.47 to 28.37 0.431
No-Elevation Ice 26.82 1.66 25.88 to 27.76 22.68 1.59 21.78 to 23.58 2.49
Elevation Ice 26.65 1.74 25.67 to 27.63 22.09 1.52 21.23 to 22.95 2.62
Treadmill Ice 27.03 1.60 26.12 to 27.94 23.37 1.66 22.43 to 24.31 2.29
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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

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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

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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

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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

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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.

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Acknowledgements

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

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Questions?