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Cooling op maat: Stand van zaken m.b.t. revalidatie en recuperatie.

On the Edge

SKA CONGRESGRENSVERLEGGENDE SPORTGENEESKUNDE

5 MAART 2016

Pat Viroux – Sportkinesitherapeut

Ivo Tiemessen - Bewegingsdeskundige

Conflict of interest disclosure form

Type of affiliation / financial interest Name of commercial company

Receipt of grants/research supports: /

Receipt of honoraria or consultation fees: /

Stock shareholder: ProCcare - Founder

Spouse/partner: /

Other support: /

I have the following potential conflict(s) to report:

Validated Cold & Heat Treatment Protocols

Professional Customized Athlete Care

Value of Compressive Cold and Heat Treatment ProtocolsFOCUS ON CLINICAL DECISION !

Customized Cold Treatment Protocols

• Why are we always using the 20 minutes rule in cold therapy in order to treat each specific injury?

• Why are we immersing 10 minutes in 15°C water, for each athlete, in each sport, in order to enhance performance recovery?

• Why are we exposing each athlete to extremely cold air (-100C) for 3 minutes in order to enhance recovery, treat inflammation or optimize vitality?

• Although cold, heat and compression are the most used modalities in sports clubs, everybody has questions about the use of it.

• Research tells us that a one-size-fits-all treatment limits the effectiveness of cold and heat application.

Cooling op maat: Stand van zaken m.b.t. en recuperatie.

On the Edge

SKA CONGRESGRENSVERLEGGENDE SPORTGENEESKUNDE

5 MAART 2016

Pat Viroux – Sportkinesitherapeut

www.sportccare.com

revalidatie

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Indications Cryotherapy

• Inflammatory response: impact on cardinal sings

• Acute, chronic or postsurgical pain

• Prevent edema formation

• Prior to, or in conjunction with, rehabilitation exercises

• Spasticity accompanying central nervous system disorders

• Acute or chronic muscle spasm

Physiological effects of Cooling• Decreased temperature

• Decreased inflammation

• Decreased metabolism

• Decreased or increased pain

• Decreased muscle spasm

• Increased muscle stiffness

• Decreased arthrogenic muscle inhibition

• Decreased circulation Not all are beneficial; the specific modality you use and how applied will make the difference in the physiological response and thus the therapeutic effect !Knight KL. Science and art of musculoskeletal modalities, 2012.

Common Misconceptions of ‘Cooling and Inflammation’

•Do you need to limit or eliminate inflammation?

– No. Inflammation is necessary.

• Repair will not occur without inflammation.

– You cannot eliminate inflammation.

– You can only minimize the signs of inflammation.

•Rubor: redness

•Calor: heat

•Edema: swelling

•Dolor: pain

•Funca laesa: functional loss

Each of these signs will occur to some degree when tissue is injured and the body responds

with the inflammatory process.

Cryotherapy and Orthopedic Injury Care

• Inflammatory Response Phase – Acute Care (0–4 days)

•Emergency care (on site)• Immediate care (0–12 h)•Transition care (12 h to 4 days)

•Proliferation Phase – Sub-acute Care (5–14 days)

•Maturation Phase – Post-acute Care (>14 days)

Immediate Care

Transition Care

RICES

• Rest

• Ice

• Compression

• Elevation

• Stabilisation

Cryotherapy and Orthopedic Injury CareSecondary Cell Injury

• Prevention of damage to healthy cells not injured at the initial trauma

• Acute continuous treatment (5hr)with cold retards secondary injury

Merrick et al. 1999

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• Local tissue cooling

• Results in significant reduction in leukocytes.

Lee et al. 2005

Secondary Cell Injury Secondary Cell Injury

White blood cells

• Reduced the number of adhering leukocytes

Blood flow and Edema

• Edema formation significantlyreduced.

Schaser et al. 2007

• Cryotherapy reduces inflammation and secondary free radical production

Schaser et al. 2007

Secondary Cell Injury

Cryotherapy Reduces Inflammatory Response Without Altering Muscle Regeneration Process and Extracellular Matrix Remodeling of Rat Muscle. Vieira et al. Sci Rep. Jan 2016.

Decreases muscle spasm

• Cold reduces muscle spasm by suppressing the stretch reflex by two mechanisms

Reducing the threshold of afferent nerve endings.

Decreasing the sensitivity of muscle spindles drop of 5°C.

David Rice, Arthritis and Rheumatism 2010

Decreases AMIArthrogenic Muscle Inhibition

Muscle injuries. Biology and treatment.

Järvinen et al. Am J Sports Med 2005

CAPILLARY FILTRATION PRESSION = (CHP + TOP) − (THP + COP) + EFP

EFP: External force pressures = COMPRESSION

Impact of Compression and Elevation on Edema Cryotherapy during Proliferation Stage

Clinical Decision based upon:

• Physical examination

SwellingRednessHeatPainLoss of function

• Patient interview

• Response to prior treatment

TRANSITION WAYPOINT

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Cryotherapy during Rehabilitation

Goals of Cryotherapy:

• Facilitate exercise & rehabilitation

• Pain management

• Limit analgesic use

• Limit arthrogenic muscle inhibition (AMI)

p. 19

Clichés are Sometimes Relevant

• Heat before

• Ice after

The activity during rehab sessions very often reactivates the

acute inflammatory process….so cooling would still be the best

choice post rehab sessions!

Exceptions prove the rule

• Cartilage Injury

• Status after Cartilage Repair Surgery

• Chronic Cartilage conditions

•Decrease intra-articulare temperature and pressure!

• Michael M. Reinold, PT. Journal of Orthopedic and Sports Physical Therapy, 2006

• Kai Mithoefer, MD. Journal of Orthopedic and Sports Physical Therapy, 2012

Immediate Care: ICE – RICE – PRICE - …

• PRICE needs updating, should we call the POLICE? C M Bleakley et al – BJSM 2012

• P = Protection

•OL = Optimal Loading

• Encourage ROM within available limits

• Assists collagen alignment

• Maintains neurological loop

• Decreases the amount of function lost

• Ice – Cooling

• Compression

• Elevation

It may Stinga little…

Cryotherapy, what’s new?

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Cold versus Heat Thermoreceptors

Wide dynamic range neurons:

• Trigger pain if to cold or to hot…

is what we first feel…

but primary benefit (most often) =

alter cell metabolism.

Physical Laws

• Fourier Law H = k A t (∆T/∆L)

• Law of Grotthys Draper

•Arndt-Schuldt Principle

• Physical Stress Theory

• Rate of Conducution:Heat Storage Capacity of Modality

It is Pivotal that Practitioners are Familiarized with Thermodynamics of different modalities.Costello JT et al, 2O12

Physical Laws

• Fourier Law H = k A t (∆T/∆L)

• Law of Grotthys Draper

•Arndt-Schuldt Principle

• Physical Stress Theory

• Rate of Conducution:Heat Storage Capacity of Modality

It is Pivotal that Practitioners are Familiarized with Thermodynamics of different modalities.Costello JT et al, 2O12

The magnitude of tissue cooling during cryotherapy with varied types of

compression. Tomchuk et al. J Athl Train 2010.

Temperatur Thresholds

• 12,5°C Decrease in nerve conductionMerrick et al, J of Athletic Training 2003

• 15°-10°C Maximize the decrease in cell metabolism.Bleakley et al, Am J Sports Med. 2004

• 15°-10°C Therapeutic Skin TemperatureKennet et al, J of Athletic Training 2007

Lee et al. 2005

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Compression Levels:

• 8-15 mmHg to enhanced circulation.

• 15-20 mmHg for mild swelling

• 20-30 mmHg for moderate swelling

• 30-40 mmHg for severe swelling

Intermittent Compression Parameters:

• 40 - 60 mmHg for Upper Extremity.

• 60 - 100 mmHg for Lower Extremity

•On-Off Ratio 3:1

Treatment durations

Treatment durations tend to be too short.

• Break the “20 minute” habit

• Increase treatment duration

Treatment durations

Treatment durations tend to be too short

• Break the “20 minute” habit

• Increase treatment duration

Treatment durations

Treatment durations tend to be too short

• Break the “20 minute” habit

• Increase treatment duration

Rashkovska et al. Knee Surg and Sports Traum Arthroscopy 2013

Treatment durations

Treatment durations tend to be too short

• Break the “20 minute” habit

• Increase treatment duration

A return-to-sport algorithm for acute hamstring injuriesMenduguchia et al. Phys Ther Sport 2011.

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Treatment durations

Treatment durations tend to be too short

• Break the “20 minute” habit

• Increase treatment duration

Treatment durations

Treatment durations tend to be too short

• Break the “20 minute” habit

• Increase treatment duration

• Individual variables

1 cm intramuscular depth:

• < 8 mm: rate of 0.72° C/min/1 cm

• 10 - 18 mm: rate of 0.45°C/min/1cm

• > 20 mm: 0.25°C/min/1cm

Treatment durations

Treatment durations tend to be too short

• Break the “20 minute” habit

• Increase treatment duration

Skinfold thickness varies by sex, activity level, sport and treatment site;

therefore, clinicians should use skinfold measurements when determining a person's cryotherapy duration.

Jutte et al. J Athl Train 2012.

Treatment durations

Treatment durations tend to be too short

• Break the “20 minute” habit

• Increase treatment duration

Meeusen et al. 1986

Treatment durations

Treatment durations tend to be too short

• Break the “20 minute” habit

• Increase treatment duration

• Depth of the Lesion

Cooling an acute muscle injury: can basic scientific theory translate into the clinical setting. Bleakley et al. BJSM, 2014

Treatment durations

Treatment durations tend to be too short

• Break the “20 minute” habit

• Increase treatment duration

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Treatment durations

Treatment durations tend to be too short

• Break the “20 minute” habit

• Increase treatment duration

Treatment durations

Treatment durations tend to be too short

• Break the “20 minute” habit

• Increase treatment duration

Practical Application of ‘Compressive Cooling’

Immediate Care

Transition Care

Proliferation Suba Care

RemoddelingRehab Care

0-6 hours 1-5 days 1-5 weeks

Healing Stage

> 5 weeksTime Since

Injury

Practical Application of ‘Compressive Cooling’

Immediate Care

Transition Care

Proliferation Suba Care

RemoddelingRehab Care

0-6 hours 1-5 days 1-5 weeks

Healing Stage

> 5 weeksTime Since

Injury

Practical Application of ‘Compressive Cooling’

Immediate Care

Transition Care

Proliferation Suba Care

RemoddelingRehab Care

0-6 hours 1-5 days 1-5 weeks

Healing Stage

> 5 weeksTime Since

Injury

• Based upon Clinical DecisionTRANSITION WAYPOINT

• Cooling versus heating

• Exceptions prove the rule

Cryotherapy Treatment Protocol: Duration, Intensity and Frequency

•Modality

• Repair Phase

• Injured Tissue

•Depth of Injury

• Personal Characteristics

Customized Cryotherapy

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Cooling op maat: Stand van zaken m.b.t. revalidatie en .

On the Edge

SKA CONGRESGRENSVERLEGGENDE SPORTGENEESKUNDE

5 MAART 2016

Ivo Tiemessen – Sportkinesitherapeut

www.sportccare.com

recuperatie Cooling op maat: Stand van zaken m.b.t. revalidatie en .

On the Edge

SKA CONGRESGRENSVERLEGGENDE SPORTGENEESKUNDE

5 MAART 2016

Ivo Tiemessen – inspanningsfysioloogwww.proccare.com

recuperatie

Should we treat these athletes with the same cryo- protocol? Or should we treat these athletes with the same cryo- protocol?

Vincent Company196 cm83 kg28 years

Dries Mertens169 cm61 kg27 year

Aim of water immersion or whole body cryotherapy

• Performance recovery can be defined as the return of the muscle to its pre-exercise state following exercise (Tomlin & Wenger, 2001).

• Why are we using water immersion as a recovery strategy?

• 1. Soreness

• 2. Secondary damage

• 3. Functional impairment

• Physiological principles:1. Hydrostatic pressure effects (CWI)

2. Temperature effects (CWI and WBC)

Overall comparison- Effectiveness from literature

CWI CWT TWI HWI WBC

Physiological mechanisms/

++ ++ + + +

Theory -Hydrostatic effect-Thermal gradient

-Hydrostatic effect- Thermal gradient

(superficial)

-Hydrostatic effect

-Hydrostatic effect- (negative) Thermal

gradient

-Thermal gradient

Applied research

Physiologicaloutcomes

++ ++ + - +

Performance outcomes

++ ++ +/- +/- +/-

Subjective outcomes

+++ + - - ++

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Guidelines from literature

• Duration: between 10-20 minutes, lack of studies

• Intensity: Stronger effects in moderate (8-15°C) temperatures

• Timing: As soon as possible after activity

• Take time in training cycle into account

Poppendieck et al. 2013Versey et al. 2014

Physical reactions with water immersion

Which factors should they take into

account to have an optimal benefit?

1. Type of activity

• Own Review (2012):

• Results of positive studies

• Combination duration and temperature:

• Colder temperature for sports with high mechanical and metabolic load

• Duration effect is less clear

X= Endurance sports•= Team sports

2. Type of Immersion position: partly or whole body

• Poppendieck et al. (2013):• Exercised limb immersion -> ↑ 1.1%

• Whole body immersion -> ↑ 5.1%

• Whole body immersion should be recommended for both CWI as CWT

• Small influence of head cooling during WBC (Louis et al. 2015)

• Position: Leeder et al. (2015):

• Standing versus Sitting

• High hydrostatic pressure

• Seated > Standing (p=0.001) for DOMS

3. Hyperthermic state

• Exercise and environment: Tc increase

• Thermo-neutral state is recommended for recovery

• Elevated core temperature -> CWI• Benefit from decrease in Tc

• Lower core temperature -> CWT or WBC• Prevent Tc from further decrease

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4. Individual characterictics (1): Gender

Own study (submitted, 2016):

• Difference in muscle power and strenght recovery between men and women

• Recovery of women > men

• Body surface area to lean body mass ratio significantly correlated with outcome

4. Individual characterictics (2): Adipose Tissue

• Subcutaneous adipose tissue thickness insulates the body against heat loss

• Different durations in order to achieve similar effects intra muscular

• “Clinicians should measure skinfold thickness to determine an appropriate cryotherapy duration.” (Jutte et al. 2012)

Otte et al. 2002

Critical factors to increase efficacy

In summary

• 1. GOAL (acute- chronic-sleep enhancement)

• 2. Type of activity: high or low mechanical/metabolic load

• 3. Type of immersion position

• 4. State of body: hyper- or normothermic

• 5. Personal characteristics: gender, age, subcutaneous adiposity

Customized recovery!

Own Study (submitted 2016):

• HRV after Customized CWI > HRV standard CWI> Active Recovery

• Relative muscle power recovery customized > Relative muscle power recovery standard

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