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Peripheral Blood Flow

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Title: 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

6
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

7
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

10
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

11
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

13
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.

14
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.

15
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

16
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

17
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)

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

19
Procedures
  • Total of 18 images
  • Over 5 days, within a 2 week time period
  • Each session lasted about 45 minutes to 1 hour

20
Protocol
  • Equilibration for 15 minutes
  • Pre-Image taken
  • 15 minute Treatment
  • Initial Post-Image taken
  • Sit for 15 minutes
  • 15-minute Post-Image taken

21
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
22
Images
15 Minutes after the treatment
Before Treatment
Pre
15 Mins. Post
Immediately following the treatment
Initial Post
23
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

24
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)

25
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
26
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
27
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

28
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

29
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

30
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

31
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.

32
Acknowledgements
  • A special thank you to
  • Dr. Pascoe
  • Dr. Sefton
  • Ceren
  • The Fellows
  • The Kenny Howard Fellowship

33
References
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