Cryotherapy for Health

MUSCULOSKELETAL SYSTEM

2.1. Ankylosing spondylitis

Ankylosing spondylitis is an immune-mediated inflammatory rheumatic disease that affects movement. It is characterized by ossification and curvature of the spine, although it can also affect joints out of the spine, especially lower extremities and less often internal organs.

The inflammatory process produces pain, stiffness and restriction of joint function. Severe pain may eventually produce tendon inflammation.
Ankylosing spondylitis is nowadays intractable addressing its causes. Therefore, treatments aiming to inhibit pain and inflammation turn out to be more important. The treatment has to be multidisciplinary, as other treatments apart from the medication therapy are used as well, such as physiotherapy, physical therapy and, in case of necessity, radiotherapy. Whole-body Cryotherapy is today an integral element of the treatment for certain conditions. Its effect is sufficiently proved.

This therapy should be used within the framework of a clinical treatment -inpatient- consisting of 2 sessions per day (or 3 in case of great activity) during 2 to 3 weeks. Medical evaluations about the progress of the treatment should take place every 2-3 days.
Nevertheless, in outpatient cases, 10-15 sessions of exposure to cold are usually sufficient even when there is a high degree of inflammatory activity. This causes a relief of the symptom picture in terms of pain reduction and movement restrictions. A shock treatment consisting of 5 sessions during the 2 first weeks using a medium intensity Moderate upper area program is recommended to this effect. It will be followed by a maintenance therapy consisting of 2 or 3 sessions per week during 1 or 2 months using the same program 3 or 4 cycles per year will be planned.

Additionally, Whole-body Cryotherapy is particularly relevant for diseases connected to psoriasis or chronic intestinal inflammation (Crohn’s disease). Both of them are considered as autoimmune diseases.

2.2. Arthrosis

It is a degenerative joint disorder produced by cartilage wear and tear. Arthrosis is the most common rheumatic disease. It causes pain, inflammation and reduction of joint movement.

Whole-body Cryotherapy can be used in all stages of the disease, but it is preferable to start in the early stage, when the cartilage is still functional.
There are several reasons for its use: arthrosis is a common disease, especially among the elderly. Besides that, there is no possibility of offering a treatment focused on the very cause in these days, so there are studies that try to find efficient symptomatic treatments, and Whole-body Cryotherapy has given good results thanks to its systemic effect. This is important at different levels, since arthrosis does not usually affect just one joint, but several (big and small). This, unlike local therapies, makes Whole-body Cryotherapy advantageous because it works simultaneously on all the spots and joints affected.

Moreover, thanks to its effects, other clinical aspects related to emotional factors, among others, are also improved. Another reason supporting its use is the fact that its therapeutic effect, in relation to pain and inflammation, often lasts several months or even longer.
Arthrosis develops directly in the joint cartilage, where micro-fissures enlarge gradually. The cartilage scrapes and produces waste that moves freely through the joint. Plus, some tissue structures and small pieces of cartilage may be detached or pulled out. The cells in the damaged cartilage tissue release inflammatory substances, and the inner membrane of the capsule gets inflamed. This means that the cartilage will not stop suffering damage.

This wear and tear is favored by several factors: less stretch and less water content in the cartilage, thinning tissue and limitations in nutrient supply and waste disposal. These factors come with aging and decrease the capacity of cushioning. Too much weight is also especially negative for joints like hip joint and knee joint. This increases pressure on cartilage and affects their functionality.
Since joint tissue does not have its own blood supply, nutrients and oxygen are transmitted through synovial fluid coming from the inner membrane of the joint capsule. This requires an optimal pressure index on the cartilage, meaning that a permanent disorder at this level leads to a chronic lack of supply to the tissue.

Nevertheless, other factors that facilitate the disease to a large extent are hormonal influences (post-menopause arthrosis of the hands) or partial and chronic deterioration of the joint functions due to bad posture, repetitive efforts and insufficient joint movement.
In an advanced stage, the joint becomes significantly swollen and warm, especially if the arthrosis has been activated by inflammatory processes.
The development of arthrosis is often accompanied by severe pain caused by:

● Increase of pressure on the joint surface of the bone affected.
● Inflammation of the inner membrane of the joint capsule.
● Expansion of the joint capsule as a consequence of the joint effusion.
● Chronic irritation of the peri-articular tissue structures, ligaments, tendons and muscles.

The pain mainly appears during and after exercise and is relieved with rest and at night. However, pain during rest will appear later leading to greater movement limitations.
Arthrosis is hardly ever self-healed. Nevertheless, a repairing process of connective tissue can be activated in the final stage of the disease as a result of chronic inflammation and damage of bones. This process leads to a partial substitution of the lost cartilage, a reduction in symptoms and a better functionality.
Many of the problems associated with arthrosis are due to the fact that this disease affects the muscles and the connective tissue. This is why the response to pain in damaged joints results not only in changes in proprioception in the joints, but also in the peri-articular tendons and muscle groups. However, a normal nerve transmission from these areas is essential for the proper functioning of muscle contractions and the adequate maintenance of the sense of balance. As a result of the modified afferent impulses, there can be coordination disorders and instability when walking.
Whole-body Cryotherapy has an impact on the main components of the disease:

● Onset of pain.
● Inflammatory process.
● Functional alteration of muscle groups near joints.

Although the pain caused by arthrosis depends on different harmful factors, whole- body cold sessions allow to reduce pain significantly and to counter joint blockade. This procedure enhances the conditions to use other techniques such as passive and active kinesiotherapy. The patient should try to avoid too much tension and pressure when doing exercise after pain is gone relatively fast. The therapist should help find a reasonable level of activity in order to improve the nutrient supply to the cartilage through the normalization of the pressure in the joint. Plus, a wider movement stimulates the substance supply to the cartilage cells.
As it happens with the pressure level, a certain degree of viscosity of the synovial fluid is necessary to maintain the metabolic balance of the joint cartilage.
In this regard, Whole-body Cryotherapy has an advantage over standard local cold applications. It is a brief therapy that reaches the deepest layers of tissue and inner space of the joint for a short time in order to avoid negative effects on the flow properties of the synovial fluid.

Cold applied throughout the body effectively reduces not only pain, but also the increasing temperature in the area, as well as the swelling. This means that the inflammatory process is completely considered from a therapeutic point of view.
Whole-body Cryotherapy does not fully replace other demonstrated treatments for arthrosis. It must be part of a multidisciplinary therapeutic concept including medicine intake, kinesiotherapy right after the cold sessions, muscle relaxation techniques and surgical treatment.
Besides that, it is possible to discuss with the doctor whether a -temporary- reduction or suspension of the medicine treatment can take place if the results of cryotherapy are satisfactory.

2.3. Central cord syndrome

Whole-body Cryotherapy is also indicated for central cord syndromes, especially for the cervical and lumbar spine. These syndromes are part of our everyday life under designations like “disc injury”, “low back pain” or “sciatic pain”.

These disorders usually called “back pain” are caused by degenerative changes of the intervertebral discs and the zygapophysial joints. However, the muscles and ligaments that support and fix the spine can also be affected both somatically and functionally. Inflammatory processes can be found parallel with the degenerative changes at their onset.
Back pain has a strong tendency to become a chronic disorder and leads to physical inactivity, locomotive system stress and depressive-reactive clinical pictures.
A cold treatment can complete and even replace other standard therapies. Muscle tension decreases when nociceptive impulses are reduced. When cryotherapy is used in time and in combination with behavioral interventions, it is possible to effectively stop this disorder before it becomes chronic. Besides, when there is pain after a surgical intervention of the spine, the results of using Whole-body Cryotherapy are really compelling.
It is usually recommended to apply a series of up to 20 cold sessions to treat central cord syndromes in order to reduce the painful muscle tension. The treatment will consist of 3 sessions per week, alternating days, during 7 consecutive weeks using the Moderate upper area program. This regime is to be retaken 3 to 4 times per year.

2.4. Tendinopathy

Tendinopathies are degenerative diseases of the connective tissue of tendons (tennis elbow, Achilles tendonitis, heel pain). Their inflammatory symptoms are pain, loss of strength and dysfunction, haematoma or pain when contracting and stretching. They are favoured by a chronic overload, and usually respond quite well to Whole-body Cryotherapy.

Pain when moving is related to these disorders. It is sometimes very severe, and is relieved after 5 to 10 sessions. However, early efforts are to be avoided, and the return to normal habits must be gradual.

AUTOIMMUNE DISEASES

4.1. Fibromyalgia

Fibromyalgia patients often experience a variation in the therapeutic approach strongly dependent on their doctor’s opinion on the cause of the disorder. In fact, the origins of fibromyalgia remain unknown, and the attempts to explain their pathogenic causes are still too weak to establish a standard evidence-based treatment. Unfortunately, this situation leads to frequent changes of doctor, which is very harmful for a successful therapy. Plus, patients do not always believe that great part of the therapeutic potential lies in themselves.
In order to evaluate the therapeutic importance of cold, it is assumed that fibromyalgia is mainly related to a stress and pain management disorder whose characteristics are:

● Chronic development
● Pain of variable intensity throughout the body
● The possibility of a variety of vegetative, functional and mental disorders.

Main symptoms of fibromyalgia

● Spontaneous musculoskeletal pain for more than three months near the spine, between the muscles surrounding the joints, and low pain threshold.
● General increase of tactile sensitivity or when moving the aching areas.
● Memory disturbances.
● Fatigue and asthenia.
● Sleep disorders.
● Morning joint stiffness.
● Headache and migraine.
● Casual depressive mood and state of anxiety.
● Decrease of stress tolerance.

A multi-modal approach is always pursued when treating fibromyalgia. It includes several parts which are not to be forgotten when Whole-body Cryotherapy is used, such as:

• Finding the possible somatic or psychosocial causes.
• Physical therapy.
• Moderate activity.
• Relaxation therapy.
• Therapies to overcome pain and stress.
• Pharmacological treatment.

Whole-body Cryotherapy has been successfully used for some time now to treat fibromyalgia, but it is only to be used if the patient tolerates it and it does not affect negatively their overall status. However, patients that have gone through heat treatments are often reluctant to believe in therapeutic cold. Nevertheless, people usually change their mind after a test session.

Whole-body Cryotherapy can be objectively proved as better than heat treatments through methods such as the measurement of pain, since chronic pain is the main symptom of fibromyalgia.

There is also a tendency to muscle fatigue. The result: restrictions on joint mobility. After 20 or 30 exposures to cold, great improvements can be achieved. The success rate ranges between 40% and 80 %. These oscillations depend on the possibility of developing a memory for pain. In the interest of a sustainable success, Whole-body Cryotherapy should be combined, if possible, with activation treatments. It is recommended to practice gymnastic exercises within the 3 hours following the cold session. This will slowly increase physical activity and avoid pain. The tension and stretching of muscles should not last long. It must be kept in mind that pain and tension can interfere in the muscle groups to varying degrees. The result is often a cautious attitude towards these muscle groups at the expense of others. The gymnastics have the aim of achieving a balance between these differences. A moderate and controlled endurance exercise can complement the therapeutic exercise program. It is of vital importance to find your own limits and try not to overdo competition exercises, respect fatigue, write down your improvements without pain and admit your results with a positive attitude.

Therefore, Whole-body Cryotherapy can help regulate the level of the affected areas activity. This has a positive influence on sleep disorders that usually come with fibromyalgia, as well as on the depressive mood occasionally observed. Both sleep disorders and depressive mood are usually caused by chronic pain. Thanks to the decrease of pain and balancing effect of cold, it is possible to reach a state of restful sleep after a few days. The effects of the combination of Whole-body Cryotherapy and progressive muscle relaxation by Jacobson have been proved. This technique, along with the interaction with the resulting process of emotional balance, allows appreciating the state of muscle tension and relaxation.

The strong stimulus of cold throughout the body has a regulating effect of the state of capillary walls tension on a superficial level. This, coupled with a physical activity adapted to the capacities of each patient, leads to better mood.

The increase of irrigation of muscles described after the exposure to cold throughout the body might also lead to a regulation of metabolism in musculature and thus to a decrease of general malaise.
Finally, according to a medical study carried out at the Meprysa Polyclinic, endorsed by Dr. Armando Fernández Sánchez on 13 patients suffering from fibromyalgia, the following experimental conclusions were reached:

• Effects on the sympathetic system: Since the first session, patients have noticed an increase in their sense of wellness, feeling less depressed and more active. They say that this antidepressant and invigorating effect is very noticeable in their personal and family life. Some patients comment that they have been able to carry out sports and social activities that they previously avoided.
• Effects at the psychopathic level: patients themselves relate the improvement in their mental well-being with the treatment. After the sessions, they comment on a certain feeling of euphoria.
• Effects at the motor level: They show greater mobility and physical activity. They comment that they have felt less pain and muscle spasms.
• Effects at the dermatological level: From the third session they present better appearance of the skin.
• General effects: They refer needing less medication, such as analgesics and anti-inflammatories.

In conclusion, it can be said that the improvement is faster and more important, outbreaks diminish in users who have done more sessions more and more followed in time.

4.2.Immune-mediated inflammatory disorders

Immune-mediated inflammatory disorders are those in which the autoimmune processes have been identified as a cause of the disease. The experience in cryotherapy includes great number of these disorders: rheumatoid arthritis, ankylosing spondylitis, psoriasis (with or without arthritis) and multiple sclerosis.

What causes these diseases?

The immune system has highly specialized cells and proteins called cytokines. Under certain physiological conditions and after having detected harmful factors, they develop important functions to protect the human organism and defend it from agents that they destroy using a process of acute inflammation.

The potential to recognize harmful elements for the organism (antigens) appears during the embryonic development. It becomes an effective defense after having faced different pathogens throughout life. Nevertheless, it seems that it might stop working properly due to root causes (endogenous) or secondary causes (acquired). This would produce a loss of some of these specific properties leading to immune tolerance or absence of response to proper and foreign antigens, as well as self-aggressive immune reactions manifested by a chronic primary inflammation that destroys tissue. The cause of this phenomenon is still unknown, but genetic research is helping understand how immunology works. In this context, it has been recently discovered that a fault in chromosome 6 is responsible for the development of autoimmune diseases, including rheumatoid arthritis and multiple sclerosis. A risk gene for Crohn’s disease has been found in chromosome 16. This is a chronic inflammatory disease of the intestine that also produces self- aggression.

Although autoimmune diseases are systemic diseases (the entire body is affected), they also have very specific target organs, body areas where they affect specifically and manifestly. These are:

• Joints (rheumatoid arthritis).
• Spine (ankylosing spondylitis, mainly).
• Central nervous system (multiple sclerosis).
• Skin and joints (psoriasis, with arthritis).
• Intestine (Crohn’s disease).

Cytokine TNF (tumor necrosis factor alpha) plays an obvious main role in these processes. The over-production of this protein by cells from the immune system triggers a chain reaction of inflammatory processes that foment self-aggressive function of immune cells. New cytokines are released and activated, and the walls of the blood vessels become permeable to the aggressive immune cells, allowing them to enter the target zone or target organ. These immunological discoveries, especially the destructive effect of TNF have allowed the development of highly efficient treatments for these diseases.

4.3.Rheumatoid arthritis

The pathological processes of this autoimmune disease appear mainly in joints. The membrane that covers the joint capsule is inflamed and the structures of cartilage and bone are destroyed. New principles have been adopted for treating this disease (blocking the TNF), but the treatment still requires a complex procedure, since rheumatoid arthritis is basically a systemic disease that weakens the whole organism. Then, the medicine or surgical treatment, or eventually kynesiotherapy, physical therapy -use of heat or cold- or psychological support have to be linked to the personal coping strategies of the patients and be coordinated.

An excellent and extensive bibliography about this topic has been published by relevant self-help organizations.

Rheumatoid arthritis is a systemic, chronic and progressive disease whose cure is yet to be found despite all the therapeutic advances. Therefore, this treatment aims to produce a decrease of intensity of the symptoms in order to stop or slow their progression.

Whole-body Cryotherapy must be understood in this context as an additive physiotherapy that can help achieve the objective of the treatment if it is used correctly. It has not been conceived to replace other tested treatments, but the experience and research have shown that it usually helps reduce the medicine intake.

Whole-body Cryotherapy should be used within the framework of a clinical treatment, inpatient, two sessions per day (or three when there is great activity) during 2-3 weeks. Medical evaluations about the progress of the treatment should take place every 2-3 days.

Nevertheless, in outpatient cases, 10-15 sessions of exposure to cold are usually sufficient even when there is a high degree of inflammatory activity. This causes a relief of the symptom picture in terms of pain reduction and movement restrictions.

Therapeutic activities related to movement (kynesiotherapy, physiotherapy…) will not be abandoned under any circumstances during the cryotherapy cycles. Exercise enhances the synovial fluid in joints and benefit the nutrient supply to joint cartilage, which fights muscular atrophy caused by inactivity that would ultimately produce secondary damages, for example to the skeleton.

In essence, a cryotherapy program is advantageous in two different levels:

• It improves general mobility as well as joint capacity in up to 60 % of the patients.
• It reduces medicine intake (corticosteroids and anti-inflammatory medication) in 35 to 40% of the patients.

Pain relief can be kept by increasing the length of time of the cycle regime. The improvement in joint mobility is a long-term result whose effects can be observed during a long period after therapy.

On balance, Whole-body Cryotherapy enhances the state of health, reduces pain and signs of inflammation, improves general mobility and allows reducing medicine intake.