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Subjective evaluation of the effectiveness of whole-body cryotherapy in patients with osteoarthritis

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Abstract

Objectives One of the treatments for osteoarthritis (OA) is whole-body cryotherapy (WBC). The aim of this study is to assess the effect of whole-body cryotherapy on the clinical status of patients with osteoarthritis (OA), according to their subjective feelings before and after the application of a 10-day cold treatment cycle. The aim is also to assess the reduction of intensity and frequency of pain, the reduction of the painkiller medication used, and to assess the possible impact on physical activity. Material and methods The study involved 50 people, including 30 women (60%) and 20 men (40%). Thirty-one patients had spondyloarthritis (62% of respondents), 10 had knee osteoarthritis (20%), and 9 hip osteoarthritis (18%). The overall average age was 50.1 ±10.9 years; the youngest patient was 29 years old and the oldest 73 years old. The average age of the women was 6 years higher. The study used a questionnaire completed by patients, and consisted of three basic parts. The modified Laitinen pain questionnaire contained questions concerning the intensity and frequency of pain, frequency of painkiller use and the degree of limited mobility. The visual analogue scale (VAS) was used in order to subjectively evaluate the therapy after applying the ten-day treatment cycle. Results According to the subjective assessment of respondents, after the whole-body cryotherapy treatments, a significant improvement occurred in 39 patients (78%), an improvement in 9 patients (18%), and no improvement was only declared by 2 patients (4%). Conclusions Whole-body cryotherapy resulted in a reduction in the frequency and degree of pain perception in patients with osteoarthritis. WBC reduced the number of analgesic medications in these patients. It improved the range of physical activity and had a positive effect on the well-being of patients.
Reumatologia 2016; 54/6
Original paper Reumatologia 2016; 54, 6: 291–295
DOI: 10.5114/reum.2016.64904
Subjective evaluation of the effectiveness of whole-body
cryotherapy in patients with osteoarthritis
Tomasz Chruściak
Rehabilitation Center, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland
Abstract
Objectives: One of the treatments for osteoarthritis (OA) is whole-body cryotherapy (WBC). The aim
of this study is to assess the effect of whole-body cryotherapy on the clinical status of patients with
osteoarthritis (OA), according to their subjective feelings before and after the application of a 10-day
cold treatment cycle. The aim is also to assess the reduction of intensity and frequency of pain, the
reduction of the painkiller medication used, and to assess the possible impact on physical activity.
Material and methods: The study involved 50 people, including 30 women (60%) and 20 men (40%).
Thirty-one patients had spondyloarthritis (62% of respondents), 10 had knee osteoarthritis (20%),
and 9 hip osteoarthritis (18%). The overall average age was 50.1 ±10.9 years; the youngest patient
was 29 years old and the oldest 73 years old. The average age of the women was 6 years higher. The
study used a questionnaire completed by patients, and consisted of three basic parts. The modified
Laitinen pain questionnaire contained questions concerning the intensity and frequency of pain,
frequency of painkiller use and the degree of limited mobility. The visual analogue scale (VAS) was
used in order to subjectively evaluate the therapy after applying the ten-day treatment cycle.
Results: According to the subjective assessment of respondents, after the whole-body cryotherapy
treatments, a significant improvement occurred in 39 patients (78%), an improvement in 9 patients
(18%), and no improvement was only declared by 2 patients (4%).
Conclusions: Whole-body cryotherapy resulted in a reduction in the frequency and degree of pain
perception in patients with osteoarthritis. WBC reduced the number of analgesic medications in
these patients. It improved the range of physical activity and had a positive effect on the well-being
of patients.
Key words: whole-body cryotherapy, spondyloarthritis, knee osteoarthritis, hip osteoarthritis.
Introduction
One of various efficient approaches to therapeutic
recovery that has been exercised for many years and re-
mains in contemporary medical practice is whole-body
cryotherapy. Treatments consist of applying short cryo-
genic temperatures (below –100°C) to the whole body of
the patient in order to induce a physiological response.
Furthermore, its significant development results in the
formation of new types of cryochambers [1–5].
The treatment of patients with implementation of
low temperatures inside a cryochamber, proves to be ex-
tremely beneficial in rehabilitating the musculoskeletal
system, particularly osteoarthritis, rheumatoid arthri-
tis, ankylosing spondylitis, psoriatic arthritis, post-trau-
matic alterations, multiple sclerosis and spastic paresis.
Patients with fibromyalgia experience subjective im-
provement in reported pain and also observed slowed
conduction in sensory and motor nerves and reduced
muscle spasticity. Contraindications include: claustro-
phobia, Raynauds disease and phenomenon, cardiovas-
cular diseases (such as cardiac failure), acute respiratory
diseases and cancer [6–16]. Cryotherapy is also a highly
recommended procedure for maintaining a satisfactory
Address for correspondence
Tomasz Chruściak, Rehabilitation Center, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Wołoska 137, 02-507 Warsaw,
Poland, e-mail: Tomasz_Chrusciak@wp.pl
Submitted: 27.10.2016; Accepted: 12.11.2016
292 Tomasz Chruściak
Reumatologia 2016; 54/6
physical condition in healthy people (biological regener-
ation, competitive sports) [17, 18].
The best therapeutic effect of cryotherapy is
achieved in the treatment of lesions located in the
musculoskeletal system. It is beneficial in improving
the well-being, and physical activity and helps relieve
fatigue in patients. Treatments last from 1 to 3 min-
utes – the patients remain for about 15–30 seconds at
a temperature of –60°C inside the vestibule and for 1 to
3 minutes at a temperature of –110°C to –160°C inside
the actual chamber. Optimal results of systemic cryo-
therapy are achieved by applying temperatures ranging
from –130°C to –150°C. Cryotherapy improves blood
circulation. It also helps to neutralize the substances,
which cause pain and inflammation.
Patients suffering from rheumatoid arthritis noticed
an improvement in reducing joint stiffness, paint in-
tensity and a smaller amount of painkillers taken upon
completion of the cryotherapy sessions.
Upon completion of the cryotherapy sessions, physical
therapy is a necessary component of the healing process.
It is accomplished by a rehabilitation technique known as
cryokinetics. The technique is associated with an individ-
ually determined rehabilitation program [14–20].
The aim of this study was to assess the effect of
whole-body cryotherapy on the clinical status of pa-
tients with osteoarthritis, according to their subjective
feelings before and after the application of a 10-day cold
treatment cycle. The aim was also to assess the reduc-
tion of intensity and frequency of pain, the reduction of
the amount of painkiller used, and the possible impact
on physical activity.
Material and methods
The study was conducted at the Central Clinical Hos-
pital of the Ministry of the Interior in Warsaw at the turn
of February and March 2016, where the cryochamber
was used.
The study involved 50 people, including 30 women
(60%) and 20 men (40%). Thirty-one patients had spon-
dyloarthritis (62% of respondents), 10 had knee osteoar-
thritis (20%), and 9 hip osteoarthritis (18%). The overall
average age was 50.1 ±10.9 years; the youngest patient
was 29 years old and the oldest 73 years old. The aver-
age age of the women was 6 years higher.
The study used a questionnaire completed by pa-
tients, and consisted of three basic parts:
1. The modified Laitinen pain questionnaire con-
tained questions concerning the intensity and frequen-
cy of pain, frequency of painkiller use and the improve-
ment of mobility. The number of points in these four
categories ranges from 0 to 16, with a lower number
indicating better health of the patient.
2. The visual analogue scale (VAS) was used in or-
der for the patients to subjectively evaluate the ther-
apy after the ten-day treatment cycle. It is a reliable
and frequently used method in the evaluation of pain
intensity. The patient indicated a point on a 10 cm line
to show their pain severity, where 0 represents no pain
and 10 represents the strongest possible pain (mod-
erate pain is 1–3, 4–6 means strong pain, 7–9 is very
strong pain).
3. Subjective evaluation of the therapy. Patients as-
sessed the state of their health after treatment by choos-
ing one of the available replies: significant improvement,
improvement, lack of improvement or deterioration.
The study has been approved by the Bioethics Com-
mittee of the Central Clinical Hospital of the Ministry of
the Interior in Warsaw (no 42/2015).
Results
After the ten-day cycle of whole-body cryotherapy
(according to the subjective assessment of respondents),
a significant improvement occurred in 39 patients (78%),
an improvement occurred in 9 patients (18%), and no im-
provement was declared by only 2 patients (4%). The av-
erage baseline pain intensity in all patients was 5.1 points
(VAS 5.1 ±1.9). Upon completion of the therapy, this value
decreased to 2.6 points (2.6 ±1.6). According to the survey,
in women this value dropped from 5.1 points (5.1 ±1.8) to
2.7 points (2.7 ±1.6), and in men from 5.2 points (5.2 ±2.0)
to 2.5 points (2.5 ±1.7) (Table I).
Patients felt that before and after treatment, pain
intensity decreased by an average of 1.6 points (1.6
±0.7) to 0.7 points (0.7 ±0.5) (Tables II, VI), the frequen-
cy of pain fell from 2.1 points (2.1 ±1.0) to 0.9 points (0.9
±0.6) (Tables III, VI), the use of analgesics from 1.0 points
(1.0 ±0.8) to 0.2 points (0.2 ±0.2) (Tables IV, VI), while
the limitations on physical activity decreased from 1.2
points (1.2 ±0.8) to 0.7 points (0.7 ±0.5) (Tables V, VI).
Table I. The average degree of severity of pain before and after treatment by VAS 10-point scale
Gender Number of patients Percentage (%) Before therapy (points) After therapy (points)
p
Both women
and men
50 100 5.1 ±1.9 2.6 ±1.6 < 0.0001
Women 30 60 5.1 ±1.8 2.7 ±1.6 < 0.0001
Men 20 40 5.2 ±2.0 2.5 ±1.7 < 0.0001
293
Subjective evaluation of the effectiveness of whole-body cryotherapy in patients with osteoarthritis
Reumatologia 2016; 54/6
Discussion
Whole-body cryotherapy applied within the frame-
work of comprehensive physiotherapy is an effective
method in the treatment of osteoarthritis, contributing
significantly to improved mobility. The final outcome is
definitely better when cryotherapy is used in a long-term
therapeutic process. With proper application it does not
cause complications and provides a valuable comple-
mentary method of primary treatment [4, 9, 10, 12].
Table II. The number of patients assessing the intensity of pain before and after therapy (p = 0.0013)
Pain intensity Before treatment After treatment
Number of patients Percentage (%) Number of patients Percentage (%)
No pain 2 4 17 34
Mild 19 38 31 62
Strong 26 52 2 4
Very strong 3 6 0 0
Cannot withstand 0 0 0 0
Total number of patients 50 100 50 100
Table III. The number of patients evaluating the incidence of pain before and after therapy (p = 0.0015)
The incidence of pain Before treatment After treatment
Number of patients Result (%) Number of patients Result (%)
There is none 0 0 11 22
Periodically 16 32 32 64
Often 19 38 7 14
Very often 9 18 0 0
Continous 6 12 0 0
Total number of patients 50 100 50 100
Table IV. The number of patients using painkillers before and after therapy (p < 0.001)
The use of painkiller Before treatment After treatment
Number of patients Result (%) Number of patients Result (%)
Without painkiller 13 26 41 82
On the spot 26 52 7 14
Still small doses 8 16 1 2
Still large doses 3 6 1 2
Still very high doses 0 0 0 0
Total number of patients 50 100 50 100
Table V. The number of patients evaluating limitation of physical activity before and after therapy (p = 0.00371)
Limitation of physical
activity
Before treatment After treatment
Number of patients Result (%) Number of patients Result (%)
None 5 10 15 30
Partial 33 66 33 66
Preventing work 7 14 2 4
Requiring partial assistance 5 10 0 0
Requiring total assistance 0 0 0 0
Total number of patients 50 100 50 100
294 Tomasz Chruściak
Reumatologia 2016; 54/6
The results are a confirmation of the beneficial ther-
apeutic effects of cryotherapy in patients with degen-
erative arthritis. Cryotherapy has analgesic, anti-inflam-
matory and anti-edematous effects, decreases muscle
tension and improves microcirculation and systemic
reactions (hormonal and immune) [9–11, 13, 14].
In research connected with evaluation of the reme-
dial influence of whole-body cryotherapy in patients
with chronic neck pain syndrome, Daniszewska et al.
[21] declared that a series consisting of 10 sessions, with
the combination of kinesitherapy, greatly reduces the
pain-related symptoms and increases the movement
range of the cervical spine linked with osteoarthritis.
Likewise, Stanek et al. [22] reached the same results
with a significant reduction of pain symptoms in pa-
tients with ankylosing spondylitis, who have undergone
10 sessions of whole-body cryotherapy treatment. In-
deed, the gathered data emphasize that the decrease
in pain intensity in the selected groups of patients who
have attempted cryotherapy with kinesitherapy is con-
siderably greater than in groups of patients treated with
kinesitherapy alone. Before beginning and after ending
the treatment cycle, patients have reported their find-
ings based on the VAS pain scale.
In research comparing the analgesic effectiveness
of local and whole-body cryotherapy in patients with
chronic pain linked with degenerative changes, Miller
[23] claims success of the therapy with both procedures,
although the outcome is best achieved with whole-body
cryotherapy. Furthermore, a favorable effect of cryo-
therapy on the mental state of patients has also been
observed. The effect manifested itself in fatigue relief
and mood improvement. In addition, the success of lo-
cal and whole-body cryotherapy of knee osteoarthritis
was found in the study of Osowska et al. [24], where
both procedures are viewed as similarly effective. After
the whole-body cryotherapy sessions, the level of pain
symptoms rated on the numerical rating scale (NRS),
along with a modified Laitinen questionnaire, dimin-
ished by 26% and 38%, respectively. However, in the
group of patients treated with local cryotherapy, the pain
level also dropped, by 28% and 35%, respectively [24].
Further investigations referring to the impact of
whole-body cryotherapy in subjects suffering from rheu-
matoid arthritis confirm a positive remedial response.
Krekora et al. [25] discovered that a 10-session whole-
body cryotherapy cycle combined with exercise, greatly
minimizes the frequency and intensity of pain, morning
stiffness, amount of painkiller taken and improvement
in the context of motor activities.
The analgesic effect of whole-body cryotherapy was
also observed in studies conducted by Cholewka and
Drzazga [26] who attempted to compare the effective-
ness of procedures performed in a two-tier cryocham-
ber and a cryochamber of lingering cold. The results of
the research were approximate. The authors highlight
the fact that both types of cryochambers contributed
to an overall improvement of the overall clinical status
of patients [26].
In my study almost 80% of respondents felt that af-
ter the whole-body cryotherapy treatment, a significant
improvement occurred. In the subjective assessment,
patients focused in particular on the analgesic effect,
the ability to undertake various activities in daily life
(improvement of physical activity), relaxation and their
generally improved well-being. The therapy has been
proven effective, as indicated by the results obtained
through the Laitinen questionnaire, the VAS and the
subjective approach.
Conclusions
1. Cryotherapy resulted in a reduction in the frequen-
cy and degree of pain perception in patients with.
2. A 10-day cycle of cold treatment reduced the num-
ber of analgesic medications in these patients.
3. Cryotherapy treatments improved the range of
physical activity and had a positive effect on the well-be-
ing of the patients.
The author declares no conflict of interest.
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Whole-body cryotherapy (WBC) involves short exposures to air temperatures below -100°C. WBC is increasingly accessible to athletes, and is purported to enhance recovery after exercise and facilitate rehabilitation postinjury. Our objective was to review the efficacy and effectiveness of WBC using empirical evidence from controlled trials. We found ten relevant reports; the majority were based on small numbers of active athletes aged less than 35 years. Although WBC produces a large temperature gradient for tissue cooling, the relatively poor thermal conductivity of air prevents significant subcutaneous and core body cooling. There is weak evidence from controlled studies that WBC enhances antioxidant capacity and parasympathetic reactivation, and alters inflammatory pathways relevant to sports recovery. A series of small randomized studies found WBC offers improvements in subjective recovery and muscle soreness following metabolic or mechanical overload, but little benefit towards functional recovery. There is evidence from one study only that WBC may assist rehabilitation for adhesive capsulitis of the shoulder. There were no adverse events associated with WBC; however, studies did not seem to undertake active surveillance of predefined adverse events. Until further research is available, athletes should remain cognizant that less expensive modes of cryotherapy, such as local ice-pack application or cold-water immersion, offer comparable physiological and clinical effects to WBC.
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The aim of this article was to review current evidence about cryotherapy in inflammatory rheumatic diseases (therapeutic and biological effects). For therapeutic effects, we performed a systematic review (PubMed, EMBASE, Cochrane Library, LILACS databases, unpublished data) and selected studies including non-operated and non-infected arthritic patients treated with local cryotherapy or whole-body cryotherapy. By pooling 6 studies including 257 rheumatoid arthritis (RA) patients, we showed a significant decrease in pain visual analogic scale (mm) and 28-joint disease activity score after chronic cryotherapy in RA patients. For molecular pathways, local cryotherapy induces an intrajoint temperature decrease, which might downregulate several mediators involved in joint inflammation and destruction (cytokines, cartilage-degrading enzymes, proangiogenic factors), but studies in RA are rare. Cryotherapy should be included in RA therapeutic strategies as an adjunct therapy, with potential corticosteroid and nonsteroidal anti-inflammatory drug dose-sparing effects. However, techniques and protocols should be more precisely defined in randomized controlled trials with stronger methodology.
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