The immune system is mediated by specialised cells known as cytokines. Its primary role is to recognise harmful factors and ward them off using acute inflammatory reactions. When the immune system becomes deregulated, its ability to refrain from attacking its own tissue structures is broken down. The result is chronic inflammation that leads to tissue destruction, mediated largely by the pro-inflammatory cytokine TNF-α.
Cryotherapy is an effective treatment for the following conditions:
During a session of cryotherapy, a number of mechanisms contribute to a reduction in the factors that lead to the inflammatory cascade:
The circulatory system undergoes dramatic peripheral vasoconstriction followed by rebound vasodilation. This improves peripheral vascular tone at the same time as reducing histamine release. Oedema is decreased as a result.
The neuromuscular system responds by:
- Decreased troponin 1
- Decreased creatine kinase
The immune system responds with:
- Increased white blood cells
- Increased anti-inflammatory cytokines
- Reduced pro-inflammatory prostaglandin PGE2
The endocrine system responds with:
- Increased noradrenaline
- Increased β-endorphins
- Increased adrenocorticotropic hormone (ACTH)
- Increased pro-opiomelanocortin (POMC)RHEUMATOID ARTHRITIS
RHEUMATOID ARTHRITIS (RA)
is a chronic inflammatory autoimmune disorder where the body attacks its own connective tissue. The primary focus is the joints, with inflammation of the synovial membranes that line the joints, and eventually also the destruction of cartilage and bone. It is commonly systemic and can also affect other organs in the body including skin, eyes, blood vessels and the lungs.
There is currently no known cure and the goal of treatment is to decrease disease intensity and delay progression. Drug management relies on anti-inflammatory and immune-blocking mechanisms. New therapies focus on blocking TNF-α, and although they are effective in delaying disease progression, localised and systemic adjunctive therapies remain important modalities in the management of rheumatoid arthritis. in
Role of Cryotherapy in RA
Cryotherapy, both localised and whole body, has been used in the management of the disease since it was first described in Japan in 1978. It is a highly beneficial adjuvant therapy, with studies showing multiple benefits, not least of which is an improved ability to do physiotherapy, significantly improving the outcome of a course of treatment.
Summary of benefits of Whole Body Cryotherapy in RA
- Improvements in well-being
- Decreased swelling and oedema
- Decreased use of NSAIDS in up to 40% of patients
- Relief of symptoms
- Reduction in pain and restriction of movement
- Improved ability to do physiotherapy directly following a treatment
- Reduced disease activity
- Decreased inflammatory markers: Decreased pro-inflammatory cytokines TNF-α and interleukin IL-1
- Improvements can still be seen three to six months following a course of treatments
Benefits of localised cryotherapy in RA
- Decreased ESR
- Decreased histamine levels
- Decreased scores on the Disease Activity Score (DAS28)
- Reduced joint oedema and swelling
- Improved handgrip strength measured via sphygmomanometer
- Improved muscle strength measured via EMG
- Improved joint mobility: increased range of motion and reduced stiffness
- Decreased morning stiffness
- Reduced pain (measured using visual analogue scales) lasting up to two months
- Decreased pain during examinations
Suggested treatment protocols in RA
Protocols generally suggest WBCT treatments up to three times a day for 2- 3 weeks during phases of increased disease activity, with ongoing assessment of the efficacy of the treatment. Studies have shown relief of symptoms, reduction in pain and restriction of movement, reduced disease activity and decrease in inflammatory markers after 10 to 15 sessions, even with high inflammatory disease activity. Longer term benefits are seen after longer courses of treatment (20 to 30 sessions).
- Localised cryotherapy protocols show maximum benefit when done twice a day for at least 10 days.
Ankylosing spondylitis is an inflammatory arthritis that predominantly affects the spine, although it can also affect other joints, tendons and organs. Formation of new bone in the spine and joints leads to stiffness and fusion resulting in a characteristic stooped posture. The inflammation leads to joint pain and stiffening, restriction in movement and pain at tendon insertions. Systemic symptoms include fatigue, fever and loss of appetite. In rare cases, the eye (uveitis), heart and lungs may be affected.
The disease can be accompanied by psoriasis or chronic intestinal inflammation including Crohn’s disease.
There are no known cures, and management is aimed at symptom control and delaying disease progression. Management includes anti-inflammatory drug treatments, physical therapy and irradiation therapy in more severe cases. Benefits have been seen with whole body and localised cryotherapy when used in conjunction with these therapies.
Benefits of WBCT in ankylosing spondylitis
- Decreased inflammatory markers
- Decreased CRP
- Decreased immunoglobulins (IgG, IgA)
- Decreased seromucoid
- Significant improvements in spinal mobility
- Pain relief
- Improvements in sleep quality and quantity
- Reduced joint swelling
- Reduced morning stiffness
- Reduced medication intake
- Improvements in joint mobility
- Improvements last up to 6 months following a course of treatment
Suggested protocols for WBCT in ankylosing spondylitis
Protocols suggest 10 to 20 treatments of between two and three minutes at a time over a period of two weeks, in conjunction with physiotherapy or a supervised exercise programme.
PATIENT STORY (extract from POWER FROM THE COLD, Papenfuss 2012)
“I would now like to mention the case of one gentleman suffering from Bekhterev’s disease (ankylosing spondylitis) who was treated with whole body cryotherapy at the health center in Bad Haering. The disease had really managed to depress him completely over the years in fact. When I met him for the first time and asked him what he wanted from the therapy, the modesty of his answer completely surprised me: “I just want to be able to turn my light on and off in my apartment again, I haven’t managed to be able to reach the light switch for a long time”. This desire was already outdone after just a few days of intense cold application. When I met him again in the spring of the following year, he told me full of pride that two three week serial cold therapies had already recuperated him to the extent that in the preceding winter he was able for the first time in many years again to stand once again on his beloved skis, and indeed do so over a course of more than 150 kilometers!”
Psoriasis is an auto-immune mediated chronic inflammation of the skin, characterised by patches of red or white scaly skin. Normal skin cells flake off every four weeks and new skin cells grow to replace the ones that are lost. In psoriasis, skin cells known as keratinocytes grow too quickly and build up to form the thickened scaly patches. It appears most often on elbows, ankles, scalp, hands, feet and lower back and can also affect fingernails and toenails. In some cases, psoriasis leads to inflammation in the joints leading to psoriatic arthritis.
Benefits of WBCT in psoriasis
Results are most obvious in the skin with decreased itchiness and flaking within a few days
Results have been shown to last for 3-6 months after a course of treatments
Reduces inflammation in swollen joints in psoriatic arthritis
Recommended protocols for WBCT in psoriasis
Protocols suggest 25 to 30 treatments of between two and three minutes at a time over a period of two weeks.
Multiple sclerosis (MS) is a disease of the central nervous system in which the immune system attacks the myelin sheath that surrounds your nerves and aids in the conduction of nerve signals. Damage to the myelin sheath disrupts the signal between your brain and the rest of your body and in time, the nerves themselves are damaged. Reactive oxygen species generated in excess lead to cell death and oxidative stress which has been implicated as a key mediator of the demyelinization..
MS is characterised by a large number of symptoms that change in incidence and intensity depending on the nerves affected. There are a number of forms of MS that vary in their course of progression.
There are no known cures for MS. A number of medications are available that target disease progression, delay relapses and alleviation of symptoms.
Cryotherapy has been shown to increase a general sense of wellbeing, and it was on this basis that health centres started to use WBCT as a therapy in MS. Since that time, a large number of other clinical benefits have been published.
Benefits of WBCT in MS
Generalised improvement in MS has been noted, and the overall therapeutic effects are attributed to the multi-component effect of WBCT: influencing the central nervous system, regulation of muscle activity, inhibition of inflammation, pain relief and the effects on the limbic system, with a positive effect on emotional wellbeing.
Studies have demonstrated the following effects:
- Reduced fatigue
- Pain reduction (predominantly secondary pain arising from spinal posture and consequent joint strain)
- Improved quality of life
- Decreased muscle spasticity
- Improved muscle activity on a functional EDSS score
- Reduced nystagmus
- Improved body stability when standing
- Increased physical fitness using an exercise tolerance test
- Decreased inflammation
Suggested treatment protocols in MS
Recommended treatment courses are 20 treatments of between 2-3 minutes at a time, done 2-3 times a year in association with physiotherapy or supervised exercise programmes.
Fibromyalgia is a disorder associated with widespread musculoskeletal pain, pressure-sensitive pressure points, fatigue, difficulty sleeping, headaches, depression and cognitive difficulties – known as “fibro fog”. Other symptoms include abdominal pain, urinary incontinence, tendinitis and temporomandibular joint disorders. Symptoms often begin after a traumatic episode, giving birth, surgery, infection or a period of stress but there may be no recognisable triggering event.
The cause is unknown. People with fibromyalgia have been found to have abnormally low levels of serotonin, noradrenaline and dopamine in their brains, leading to reduced effectiveness of the body’s natural endorphin painkillers. They also have increases of a chemical known as “substance P” which has been shown to amplify pain signals.
Fibromyalgia is more common in women than men, and there is often a family history, or a history of another rheumatic condition e.g. osteoarthritis, systemic lupus erythematosus, rheumatoid arthritis or ankylosing spondylitis.
Management involves a number of modalities, and drug treatments are either aimed increasing serotonin levels, or at managing specific symptoms. Both localised and whole body cryotherapy are widely used in the management of fibromyalgia.
Benefits of WBCT in fibromyalgia
- Analgesic effects
- Reduction in the number of painful pressure points (Nestler EJ et al, 2002)
- Decreased intensity of local and generalised pain
- Reduction in muscle rigidity
- Improvement of fatigue
- Improved sleep
- Improvement in mood
- General improvement of state of wellbeing
(Zagribelny Z et al 1999)
Protocol for management of fibromyalgia
Between 20 and 30 treatments of between two and three minutes at a time, combined with gradually increasing exercise routine or physiotherapy leads to lasting improvement of symptoms.