Gymna CRYOFLOW ICE-CT User manual

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Treatment Guide
Gymna Cryoow ICE-CT

Copyright GymnaUniphy NV, 2014
GymnaUniphy NV
Pasweg 6A, 3740 Bilzen, Belgium
Phone [phone] • Fax [phone]
www.gymna.com • inf[email protected]
Manufacturer:
Uniphy Elektromedizin GmbH & Co. KG
Neuendorfstr. 19b, 16761 Hennigsdorf,
Germany

4
Guided Therapy System (GTS) 6
1. Introduction 7
1.1 Denition 7
1.2 History 7
1.3 The notion“thermal shock” 8
2. The Eects of cryotherapy 9
2.1 Local anaesthesia (analgesia) 9
2.2 Anti-inammation 9
2.3 Neurological eects 10
2.4 Vasomotor reactions 10
3. Airow therapy 12
4. Indications/Contra-indications 13
5. General applications 14
5.1 Skin temperature 15
5.2 Thermal shock 16
6. Objective list 17
6.1 Pain relief & RICE concept 18
6.2 Swelling 19
6.3 Spray and stretch treatment 19
6.4 Shockwave therapy 20
Contents

5
7. Indications 22
Achillodynia 23
Ankylosing Spondylitis 24
Arthritis 25
Arthrosis 26
Bursitis 27
Cancaneal Spur (heelspur) 2 28
Carpal Tunnel Syndrome 29
Cervicobrachial Neuralgia 30
Epicondylitis 31
Fibromyalgia 32
Frozen Shoulder 33
Lumbalgia 34
Luxation 35
Lymphoedema 36
Morton Disease 37
Muscle Spasm 38
Muscle Strain 39
Osgood Schlatter Disease 40
Patellar Tendinitis (jumpers knee) 41
Plantar Fasciitis 42
Pubalgia 43
Rheumatoid Arthritis 44
Spasticity 45
Sprain 46
Tendinitis 47
Tendon Ruptures 48
Tendovaginitis 49
Trigger Points 50
Vascular Oedema 51
8. References 52
9. Notes 54
Contents

6
Guided Therapy System (GTS)
The latest Gymna Cryoow ICE-CT is equipped with an intelligent system for
presetting the parameters and generating useful information. This invention
is called Guided Therapy System or short G.T.S.
After establishing your treatment objective the system automatically selects the
form of treatment and the best parameters. In other words, G.T.S. establishes the
connection between the therapeutic objective and the scientic basis itself.
A device with G.T.S. follows your therapeutic thinking pattern step-by-step and
takes away the need for you to setup technical parameters yourself. This allows
you to pay more attention to your patient.
This treatment guide contains valuable information. The dierent therapy forms
are explained and the eects of the various parameters are extensively decribed.
Patient
Therapist
Evidence
Therapy Objective

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1.1 Denition
Cryotherapy is the therapeutic application of cold that can be obtained in various
ways (with ice, cold water, damp cloth, methyl chloride, carbon dioxide…).
Basically cryotherapy can be divided in three groups “conduction cryotherapy”,
“airow cryotherapy” and “sublimation cryotherapy”. With conduction
cryotherapy cold is transferred via contact on the treated spot whereas this direct
contact is avoided in the two other groups. With sublimation therapy liquid gas
(nitrogen) is used to cool down a spot whereas free surrounding air is used to
cool down the treatment zone in airow cryotherapy.
1.2 History
Cryotherapy has been used in the treatment of traumatology since time
immemorial. The use of ice and snow as therapeutically means was already
mentioned by Hippocrates (460-377 before J.-C.).
Cryotherapy has been used very frequently because of its benecial eects; but
in a completely empirical way.
The method of application of cryotherapy has gone through several evolutions,
of course, but it is especially the improvement of physiological knowledge that
has allowed us to better understand the eects and made it possible to better
determine the various elds of applications and the modes of operation.
1.3 The notion“thermal shock”
In the early seventies various studies showed that, to be really eective in
cryotherapy, a “thermal shock” had to be carried out.
The cold causes a vasoconstriction.The quicker the drop in temperature, the more
ecient the “return-reaction”. "Under normal conditions the skin temperature is
around 34° C. This skin temperature should drop as quickly as possible.
1. Introduction

8
Temperature skin
under normal conditions
Temperature skin
with eective cryotherapy
THERMAL SHOCK = DECREASE TEMPERATURE CHANGE IN A MINIMUM OF TIME
35° C
34° C
12° C
7° C

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2. The eects of cryotherapy
2.1 Local anaesthesia (analgesia)
The maximal eect is reached immediately (within 10 to 15 seconds) during the
treatment and it will remain eective, depending on circumstances, from 30
minutes to 3 hours after the treatment has been stopped (the average duration
is one hour).
When the skin temperature goes below 15° C, the coldness has the eect of
slowing down the conduction of nervous impulses. However, one should be
aware of the fact that, in vitro, a temperature below 10° C could cause damage to
the nervous system. In vivo, this limit can be xed between 5 and 7° C. However,
a thermal shock will consist of lowering the skin temperature from 34° C to less
than 15° C, but never reach a temperature lower than 5° C.
Cold will also decrease the irritability of the nociceptors (through depolarisation
of cell membranes).
2.2 Anti-inammation
The importance of inammation, of the permeability of the capillaries and of the
cellular response is directly linked to the temperature of the tissue.
Afastapplicationofcoldcausesadecreaseintheproductionofneurotransmitters,
which are responsible for the inammation. This makes it possible to decrease
the quantity of the substances that cause pain with 70 to 80 %, which results in a
less intense inammatory reaction.
By causing a vasoconstriction (arteriolar and capillary), cold will oppose the
vasodilatation of the inammatory reaction. This vasoconstriction is responsible
for a decrease of the drainage of the blood ow, for a diminution of the hydrostatic
pressure and thus for a reduction of the drainage of liquid. As a result the
plasmaextravasation, responsible for the volume of the oedema, will be limited.
We should draw attention to the fact that cold does not inhibit the drainage of

10
the liquids, responsible for the repair of the tissues. Cold will only slow down this
process.This deceleration is compensated largely by the reduction of the harmful
eects of the oedema, which will allow for a much earlier rehabilitation by means
of exercising.
2.3 Neurological eects
As already mentioned, cold can provoke a local anaesthesia (analgesia) provided
that the temperature reaches a level below 15° C. Cold also reduces muscular
spasticity.
It has been established that the amplitude of the reex response during the
stretching of the muscle decreases during and immediately after application
of the cold. This phenomenon is what led Travell to developing the “Spray and
stretch method”. This method provides very good results in spasms during
stretching of the muscle.
2.4 Vasomotor reactions
The cooling down of the tissue causes a fast arteriolar and capillary
vasoconstriction via the reexes (thermoregulation).
In 1930, LEWIS described the changes in the blood ow of the skin, when a hand
is dipped in water of 10 -12° C long enough. The reaction is the result of an axon
reex. Since then many authors described these reactions, although not
everyone follows these conclusions. Today is assumed that the alternation of
vasodilatation and vasoconstriction is caused by a decrease of the anity of the
adrenergic α-receptors. This dierence in conclusions can be explained by the
dierence in circumstances during the experiments.

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Hunting Reaction
Vasoconstriction Vasodilatation
0
1
2
3
4
5
6
7
Difference
(mm)
1 2 3 4 5 6
Days
Average difference (treated part - not treated part)
in distance Tragus - Nostril in function of time.
Not treated
Treated
If the application of cold is carried out long enough, it will be followed by a
vasodilatation. This paradoxical vasodilatation corresponds with a protective
hyperaemia. If the exposure is prolonged even more, the periods of vasodilatation
and those of vasoconstriction will follow after each other. This phenomenon is
called the “Hunting Reaction or also Escape”.
It has also been demonstrated that only cold, applied alone, has no direct eect
on the oedema. In order to have an eect, it must be accompanied by a light
compression in an inclined position. This combination will resolve the oedema
faster.
Source: M-B Bollack, A. Wilk; Etude du traitement de l’œdème en chirurgie
maxillo-faciale par le cryothérapie; Kinésithérapie scientique, 1998, n° 381, 6-23.
Average dierence (treated part - not treated part) in distance
T ragus - Nostril in function of time.

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Gymna has turned its expertise in developing a device to provide the best
possible application for this kind of cryotherapy.
With Gymna Cryoow ICE-CT new standards are being set in the cryotherapy
treatment. The Gymna Cryoow ICE-CT cools down surrounding air but is on
top of that the rst cryotherapy device to do this with a bio-feedback system,
thereby ensuring a constant temperature on the treated area.
The intelligent treatment head not only determines the temperature at the
treated area, but also ensures that the air ow automatically adjusts to the
intended (skin) temperature. This enables the therapist to setup his treatment
very easily; the therapist situates the patient in a comfortable position, positions
the treatment head on the required area, xes the temperature and from then on
the Gymna Cryoow ICE-CT will automatically adept its airow in order to reach
it continuously.
The possibilities for application of the Gymna Cryoow ICE-CT are enormous.
With Gymna Cryoow ICE-CT a more powerful device than the majority of
systems in use is combined with an additional revolutionary biofeedback system
adjusting the airow automatically.
The main disadvantage of other cryotherapy techniques is that the temperature
at the outcome of the hose can be measured, but never the temperature that
really matters: the one of the treated area itself. That’s why we have turned all our
expertise to the development of an intelligent hand piece on our Gymna Cryoow
ICE-CT. This does not only involve the determination of (skin) temperature, but
also the air ow that is automatically adjusted so that the adjusted temperature
remains constant and controlled.
3. Airow therapy

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4. Indications/Contra-indications
Indications Contra-indications
• Sports medicine and
traumatology
• Sprains/ Strains (acute)
• Bursitis, Tendinitis
• Rheumatology
• Prestretching of Muscles
• Muscle spasm
• Algodystrophia
• Neuralgia
• Postoperative surgery
• Pain
• Situations where the body
is unable to cope with
temperature changes because
of allergy, hypersensitivity, or
circulatory in-suciency
• Cardiac or respiratory
involvement
• Peripheral vascular disease
• Loss of thermal sensitivity
• Anesthetic skin
• Cold-allergy
• Raynaud’s disease
• Cryoglobulinemia
• Paroxysmal cold
hemoglobinuria
• Uncovered open wounds

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5. General applications
The eectiveness of the cryotherapy is the best during the acute phase, especially
during the rst 72 hours. Independently from the technology and or the physic
principle used, Cryotherapy should always be carried out in two stages:
1. The rst stage is the creation of the thermal shock, which means lowering the
skin temperature as quick as possible. It is important that this shock appears
quickly in order to avoid any adaptation and installation of mechanisms of
defense. Ideally, it must appear in less than 3 minutes and if one wants to
obtain “neuro-reexes”reaction, it must appear in less than 1 minute.
2. The second stage is the stabilization of the temperature. It is used for creating
and amplifying the “Hunting reaction” but also cooling the muscular tissue
(which is more in-depth and having a certain “mass”) in order to use it like
“accumulator” and thus getting a longer eect, even after the end of the
treatment. The problem here, will be to stabilize the skin temperature in a
way to obtain the eects of the cryotherapy without having the risks of tissue
damage. The ideal temperature is 12° C.
However, in order to reduce the swelling, it is advised to elevate the treated area
during the application. The treated area must be elevated above the level of the
heart. The application of a light pressure will further enhance the eectiveness
of the treatment.
Cryotherapy treatments are very simple thanks to the Gymna Cryoow ICE-CT.
The unique IR sensor measures the skin temperature and automatically regulates
the air ow. This keeps the pre-set temperature constant and optimal during the
treatment. It is a major advantage, that due to this automatic system, it is already
enough to select the obtained objective or indication and the treatment will be
done automatically.
This enables the therapist to setup his treatment very easily; the therapist situates
the patient in a comfortable position, positions the treatment head on the

15
required area, xes the temperature and from then on the Gymna Cryoow ICE-
CT will automatically adept its airow in order to reach it continuously.
Un des grands avantages est que grâce à ce système automatique, il sut de
sélectionner l’indication et tout se fait automatiquement.
5.1 Skin tempaerature
Under normal circumstances the average skin temperature is around 34° C.
By measuring the skin temperature, the infrared sensor enables us to evaluate
the stage of pathology (acute, subacute or chronic). In a more acute phase there
will obviously be more obvious signs of inammation and therefore also a higher
skin temperature. In order to avoid inaccuracies in treatment, you always have to
compare with a reference area:
• The same joint but at the opposite (healthy) side
• The upper joint at the same side of the injury
• The lower joint at the same side of the injury
Gymna Cryoow ICE-CT = The IR system makes it possible to determine the
skin temperature and automatically adjust the air ow to keep the desired
skin temperature constant.

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The established temperatures can be described in a table (like the below
example). An accurate summary to evaluate the disorder and the progress of
the treatment is acquired in this way.ératures constatées peuvent être consignées
dans un tableau (commedans l’exemple ci-dessous). Il est ainsi possible
d’obtenir un aperçu précis permettant de dresser un bilan de l’évolution de
l’aection et de l’avancement du traitement.
1234567
Treated area
Opposite side
Proximal of the
area
Distal of the
area
5.2 Thermal Shock
In order to create a thermal shock, it is enough to take the intermediate
nozzle (15 mm), to x the temperature at 12° C, and place the tube 5 to 10 cm
from the skin during 3 minutes.

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Indication Temperature Treatment time
(min.) Nozzle
1. Pain relief
Acute 12° C 0:15 15 mm
Subacute 14° C 0:10 15 mm
Chronic 16° C 0:10 25 mm
2. Inammation
14° C 0:15 15 mm
3. Swelling
Acute 14° C 0:15 15 mm
Subacute 14° C 0:10 5 mm
Chronic 16° C 0:10 5 mm
4. Post-surgical
14° C 0:15 25 mm
5. Spray & Stretch
14° C 0:03 25 mm
6. Trigger point
12° C 0:03 15 mm
7. Shockwave Therapy
15° C 0:05 15 mm
6. Objective list

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6.1 Pain relief & RICE concept
The famous “RICE” concept can easily be performed and in a very eective way
with the Gymna Cryoow ICE-CT using the objective list“pain relief”.
The letters R.I.C.E are abbreviations for: Rest, Ice, Compression, Elevation.
What is the RICE Technique?
Cryotherapy can be used in the acute setting making up an integral component
of the R.I.C.E technique to decrease pain, reduce swelling and fasten the healing
process.
The R.I.C.E technique is the golden standard in the treatment of acute sporting
injuries. The Gymna Cryoow ICE-CT does all the eects of ice in an ecient way
plus the compression due to the pressure of the airow (see picture below). The
treated area has to be positioned in a correct way. That means that the treated
area has to be higher positioned than the heart.
The R.I.C.E technique involves all the components that are needed to prevent
further injury to the damaged site immediately after the injury has been
sustained. If applied correctly and in time, the RICE technique can greatly reduce
the recovery time of an injury.

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6.2 Swelling
Concerning vascular problems, the elevated positioning of the treated zone is
of primary importance. The treated area must be elevated above the level of the
heart. You have to sweep on the vascular axis from distal to proximal. For the
lymphatic drainage, it is of primary importance to drain the ganglion manually.
You’ll use the small tube and will sweep during ten minutes at a temperature
of 15° C. Attention, in the event of suspicion of phlebitis, it is advised not to do
cryotherapy treatment.
6.3 Spray and stretch treatment
A treatment usually and eectively practised with the cryotherapy is the
treatment of muscle spasms like sti neck, tension headache, lumbago etc. using
the spray and stretch technique recommended by Travell & Simons.
In this case, the therapist cools (vaporizes) the muscle in order to decrease the
amplitude of the response reex during the stretching (which can be signicant
because of the muscular spasm) and then stretches it under particular conditions.

20
To have a clear view on all the indications relating to the spray and stretch
technique, we strongly recommend the following book: David G. Simons, Janet
G. Travell, Lois S. Simons, Barbara D. Cummings: Travell & Simons’Myofascial Pain
and Dysfunction: The Trigger Point Manual, second edition.
6.4 Shockwave therapy
Cryotherapy can be extremely well combined with Shock therapy. Shockwave
therapy can be uncomfortable, sometimes even painful. There is also the risk of
creating a bruise. The use of the cryotherapy before the treatment is benecial
due to:
• Its analgesic eect which makes the treatment completely painless and oers
more comfort for the patient. Thus it is possible to use suitable parameters
which improve the eectiveness of the therapy.
• Its vasomotoric eects decrease the risk on bruises caused by shockwave
therapy
• Its Hunting Reaction eect, it accelerates the healing process of shockwave
therapy.
Cryotherapy (thermal shock) associated with shockwave therapy improves
comfort of the patient, makes the therapy softer and increases the eectiveness.
The graph below clearly shows the great reduction of pain during shockwave
therapy in two joints (shoulder and elbow). We performed shockwave therapy
on both sides but before we did it on the left one, we created a thermal shock.