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University of Central Lancashire, Preston, Lancashire, UK Contributed by Jane Kennet, BSc, and Natalie Hardaker, BSc Hons , contributed to conception and design; acquisition and analysis and interpretation of the data; and drafting, critical revision, and final approval of the article. Sarah Hobbs, PhD, and James Selfe, PhD, contributed to the conception and design; acquisition of data; and drafting, critical revision, and final approval of the article.

Address e-mail to ku. This article has been cited by other articles in PMC. Abstract Context: Cryotherapy is the application of cold as a treatment. It is widely used and accepted as beneficial in early management of soft tissue injury. However, the most efficient cryotherapeutic agent remains unknown. Objective: To compare 4 common cryotherapeutic agents including crushed ice CI , gel pack GP , frozen peas FP , and ice-water immersion WI and to determine which agent provided the greatest cooling efficiency after a minute application.

Design: Repeated-measures design. Setting: University physiology laboratory. Participants were required to attend 1 measurement session for each agent. Results: Application of CI produced a significantly greater reduction in skin surface temperature Conclusions: The CI and WI had the greatest cooling efficiency and sustained decreased skin surface temperatures postapplication, indicating these agents are potentially the most clinically beneficial.

Keywords: thermal imaging, skin surface temperature Key Points Choice of modality should be an important part of clinical decision making.

Preapplication temperature is not a good indicator of modality effectiveness or efficiency ie, colder is not necessarily better. Thermal imaging is a useful tool for clinical cryotherapy research. Cryotherapy is the lowering of tissue temperature by withdrawal of heat energy from the body to achieve a therapeutic effect. Comparing application of cryotherapeutic agents on the quadriceps muscle, investigators consistently have identified crushed ice CI as the most effective and gel pack GP as the least effective method of lowering both skin surface and intramuscular temperature.

Therefore, CI may have a lower preapplication temperature than GP has, but these preapplication temperatures have not been compared. Merrick et al 4 attributed the apparent efficacy of CI to its ability to undergo phase change, which increases its capacity to absorb heat energy.

Efficacy is the capacity of the agent to produce an absolute cooling effect regardless of its preapplication temperature. Efficiency is the production of a desired effect with minimal waste. Thus, cooling efficiency is the ability of the cold agent to bring local skin surface temperature to equilibrium, and it includes the preapplication temperature of the agent. Preapplication temperature and efficiency of cooling agents have not been investigated.

The skin is rarely the target tissue during cryotherapy, and Jutte et al 6 reported no relationship between skin surface temperature and deeper tissue temperature. However, the skin is unavoidably the tissue that is cooled first because of its immediate proximity to the cooling agent.

Therefore, skin surface temperature serves as a useful measure in determining the cooling efficiency of cryotherapeutic agents. The skin effectively cools the deeper tissues by transferring the cooling. However, because of their lower thermal conductivity and diffusivity, adipose and muscle tissue are effective insulators, 7 which indicates that the temperature gradient attenuates as tissue depth increases. Otte et al 8 reported an increase in cooling time of deep tissue with increased adiposity.

Researchers 6 , 9 suggested that deeper tissue cooling continues on removal of the cold agent as the superficial tissues rewarm. Optimal temperature of the target tissue has not been defined. However, authors 6 , 9 reported that a skin surface temperature of Therefore, an efficient agent has a preapplication temperature within this range.

This temperature range potentially would increase patient comfort during cryotherapy and, in turn, increase patient compliance with treatment. We compared the cooling efficiency of 4 commonly used cryotherapeutic agents at the ankle and investigated skin surface temperature over a region of interest ROI during a minute rewarming period after a minute application 13 at the ankle.

Criteria for exclusion from the study included referred pain to the lower limb from spinal, pelvic, or hip joints; pregnancy; increased temperature of the ankle joint; psychological problems; systemic disease; sensory deficit; cold intolerance or hypersensitivity; and skin lesions. Before participating in the study, all volunteers completed a health status questionnaire a modified physical activity readiness questionnaire 14 and gave written consent.

All participants were required to attend 1 testing session for each of the 4 cryotherapeutic agents. Before each testing session, we administered a participant questionnaire to discover whether volunteers were still eligible for participation in the study. The validity and reliability of using noncontact, digital, infrared, thermal imaging TI cameras to measure skin surface temperature have been reported.

At least 24 hours was allowed between testing sessions. Participants removed shoes and socks from both feet and sat in a semirecumbent position on a treatment couch Doherty Medical, London, UK with both legs extended. Participants were encouraged to adopt a relaxed and comfortable position that could be maintained for the duration of the testing session.

Bare lower limbs were allowed to acclimate for 20 minutes to equilibrate to ambient room temperature, which is standard protocol when using a noncontact TI camera.

Before testing, we examined both lower limbs to ensure absence of skin wounds, lesions, or rashes. To ensure participants could differentiate warm from cold, we carried out thermal sensation testing over the local area by touching the ankle with a warm test tube and a cold test tube. A dry, cotton tea towel was placed under the right foot and taped in place on the treatment couch.

A baseline thermal image of the ankle was taken before application of the cryotherapeutic agent. The temperature of each treatment was taken immediately before and after application. The temperature of WI was taken using a probe attached to a hydrothermometer and submerged in water. On application, the FP were wrapped in a cold, terrycloth towel 13 to prevent superficial skin burns, which participants in other studies have reported after application of the agent directly to the skin. At the end of treatment, the participant returned to the original position.

All agents were applied for 20 minutes, which is a clinically relevant application time. Previous data 18 suggest that 30 minutes is a sufficient rewarming period because skin surface temperature reaches a plateau below baseline temperature within this time. Using the polygon tool within the computer software, we defined the ROI as the lateral ligament complex. The mean temperature over the ROI was taken from each image.

Statistical Analysis Ambient room temperature between testing sessions and preapplication and postapplication was analyzed using 1-way repeated-measures analysis of variance ANOVA.

We also used 1-way repeated-measures ANOVA to determine the effect of the agent on change in skin surface temperature preapplication and postapplication. Pairwise testing was accomplished with Bonferroni correction to determine differences between cooling efficiency of agents.

We used the Scheffé test to make post hoc comparisons. We used SPSS version Lowest skin surface temperatures were recorded immediately after cold application 00 minutes for all agents Figure 1. The CI demonstrated the greatest reduction in skin surface temperature Immediately after application, CI produced the lowest skin surface temperature 9.

Skin surface remained coldest for longest after application of CI Figure 1.

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