Cryotherapy

Introduction

The research paper focuses on the application of the cryotherapy in management of various conditions in the United State. Various aspect of the intervention will be discussed in detail. A lot of emphasis will be discussed on the use of cryotherapy in alternative medicine, the different types of cryotherapy and the challenges faced in its implementation, the different contraindications and its benefits.

Cryotherapy is a new technology in the field of medicine that has impacted the standard of living for many patients. It is a therapeutic technique that uses locally applied coolants to influence various physiological and biochemical process through the cooling of soft tissues of the body. Cryotherapy has a long history dating back to the seventeenth century and has an array of use to relief pain, reduce tissue damage, reduce and control edema, reduce fever, control inflammation process and stop bleeding. It has also been used to reduce muscle spasm of extrafusal and intrafusal muscles. It is also used in certain autoimmune joint diseases by slowing the action of destructive enzymes.  The cooling of cryotherapy to the body tissue is governed by two main basic physiological processes (Samrao, & Cockerell, 2013). First is the cooling effect on the soft tissues and time of application of the cooling agent which is dependent on the condition of the patient.

It uses an image-guided needle probe called a cry probe and air mainly argon gas or liquid nitrogen. This creates intense cold that freeze and destroys the target cells. It has much application in the management of certain cancers such as dysplasia of the cervix in women, treatment of skin conditions such as warts and other tumors within body organs. Cryotherapy is also called cryoablation, Targeted Cryoablation, percutaneous cryotherapy or cryosurgery. It is a minimally invasive procedure that uses liquid nitrogen to create an extreme condition that freezes and destroy the target cells and tissues (Hawkins, & Hawkins, 2016). Cryotherapy can be performed using an open surgical approach and is referred to as cryosurgery. Physicians and radiographers use image-guided techniques for example magnetic resonance, computed tomography and ultrasound to direct the cryoprobes to the target site of intervention.

Cryotherapy use in alternative medicine

Many alternative medicine clinics are using cryotherapy to manage certain conditions for certain patients who don’t like medications. The procedure is being embraced in the United States of America where certain medical doctors are specializing in the field. It is used in the management of chronic pain where the use of NSAIDs has resulted in Peptic ulcers disease. Whole body cryotherapy is improving their condition by relieving their pain.

When whole body cryotherapy is initiated, it stimulates the body’s natural healing mechanism improving the health of the patients. The whole body cryotherapy is initiated individually by the help of Cryosauna. The Cryosauna utilizes the Nitrogen gas to lower the skin temperature to 0°C while the temperature of the cabin drops to a range of between -110°C to -175°C. Following this, the brain stimulates the temperature regulatory functions resulting to reduced inflammation, pain relief, weight loss, boosting of the immunity, increased energy consumption, detoxification function of the cell and the array of these events leads to self-healing (Bleakley et al., 2014). Cryotherapy in alternative medicine helps in the natural process of pain relief by facilitating the release of exogenic endorphins. It also facilitates sleep which is essential for recovering from the inflammatory process. It also helps to reduce stress leading to an improved immune system and functioning of the body organs.

Cryotherapy is also used in sports medicine. This is where cold is applied for treatment of disease and injury and is widespread in the United States of America. It is a well-established technique for treating acute soft tissue injuries. The sports physician uses ice massage, ice packs, ice towels, gel packs, inflatable splints and refrigerated gasses. Cryotherapy has been shown to reduce pain effectively for the athletes. It also reduces the recovery time. Cryotherapy has been shown to improve postoperative pain following the surgery of joints. The relief is due to changes in temperature in various tissues of the body. Relaxation of the muscles and neuromuscular action that result from the application of the cold during cryotherapy lead to an increased threshold of pain, plastic deformity of the cells and tissues and the viscosity with decreased motor function that relief pain. Cryotherapy in sports science reduces the inflammatory process leading to less pain and swelling. It is safe with a few side effects that can be managed (Bleakley et al., 2014). Very low temperature are always avoided to prevent adverse side effects such as frost bites and nerve injury. It is contraindicated in open fractures or ischemic conditions.

Uses of Cryotherapy

Cryotherapy in alternative medicine is used to relief pain, to boost the immunity of patient, to relieve stress and to control the process of inflammation. It is used mostly in the alternative medicine as an adjuvant for other interventions options such chemotherapy and radiotherapy. Cryotherapy has an array of applications in the field of medicine. It is applied topically on the surface of the skin, surgically or percutaneously.  It is used topically in the management of eyes lesions and skin lesions (Samrao, & Cockerell, 2013). Skin lesions managed by topical cryotherapy include management of skin warts, certain dermatologic conditions, infections such as molluscum contagiosum and skin tingles.

Percutaneously, cryotherapy is used by the help of a cryoprobes and applicator needs to be placed under the skin. The cryoprobe delivers freezing Nitrogen to the site of action where it freezes target tissues.  Surgically, an incision is made, and the underlying target tissues are frozen. It is used to treat the following diseases; skin tumors, skin tags, precancerous skin moles, retinoblastoma, unsightly freckles, and nodules. It is also increasingly being used in the management of certain malignancy where surgical resection is not possible especially for prostate and cervical cancer (Hawkins, & Hawkins, 2016). There is no intensive research on the effectiveness of cryotherapy for the management of malignancy though it is selective for certain patients where full remission have been reported.

Preparation of patients for cryotherapy

When a physician is preparing to give intervention cryotherapy, there are certain factors that need to be considered. The physician should take a full history of the patient. The history of all medication should be taken, drug allergies such as the anesthetic agents and contrast material used. The physician should also take the history of other comorbidities that are contraindicated in the use of cryotherapy. A patient with coagulopathies or hemophilia requires specialized care (WHO, 2014). The doctor needs to determine the pregnancy status of female patients since imaging used may have the effect to the unborn child. It may lead to spontaneous abortions and congenital malformation to the fetus. The physician also needs to consider the age of the patient.

Young patients should not be exposed to too much radiation. The baseline test such as full haemogram, urinalysis, urea, electrolytes and creative level, liver functional test, thyroid functional test, coagulation profile and cross matching must be done. The patient should be given non-steroid anti-inflammatory agent to minimize discomfort and pain during the procedure. Ibuprofen can be started forty eight hours before the initiation of the procedure. A dose of broad spectrum antibiotics is given to prevent postoperative infection that usually occurs as a complication (WHO, 2014). The doctors should explain the procedure to the patient, the expected outcomes, and the available options, the serious side effects that might occur and receive a signed informed consent. The procedure can be done in the outpatient setting for skin and percutaneous cryotherapy. In the surgical cryotherapy, the patient must be admitted to ensure good outcomes and enhance monitoring for the complication arising from the operation such as excessive bleeding, post-operative infection, and the recovery of patients. The procedure is contraindicated in patients with coagulopathy, ischemic arterial diseases, in metastatic cancer and to patients with comorbidities.

Equipment used

The equipment required for this procedure are imaging devices such as Magnetic Resonance Imaging, Computer Tomography scan and ultrasound, a cotton swab, spraying devices, cryoprobes and the sources of nitrogen or argon gas. Laparoscopic equipment may be used where the physician intends to perform a closed surgery procedure and combine it with cryotherapy.  For treatment of skin lesion, uses spray devices or cotton swap. For tissues located inside the body, cryoprobes are used to direct the cryotherapy applicator. The imaging technique applies to help visualize the tissues (Bahn et al., 2012). In open surgery, the surgeon can spray the nitrogen gas to the target tissue. Other equipment may be used depending on the type of cryotherapy applied and the choice of the intervening radiologist.

Performing the procedure

Cryotherapy is done by trained interventional radiologist positioned in the operational room. Most of the time, the procedure is done in the outpatient setting, but some patients may require admission to enhance the procedure to be done in a well-equipped theater where resuscitation can be done when required. The patient is placed on the examining table and depending on the technique to be adopted. For topical cryotherapy, liquid nitrogen is applied to the lesion using a cotton swap and spray devices. The Nitrogen will freeze the lesion which will shrink and the cell around it will die. This will prevent further spread. Topical cryotherapy is commonly done when a footballer or an athlete hurts their knee in the field.

Tumors which are situated deep in the body, the interventional radiologist performs a percutaneous procedure where he inserts a cryoprobe through the skin to the target organ. In this procedure, anesthesia is required. It can be carried out using image guidance. The cryoprobe delivers a therapeutic dose of liquid nitrogen to the site of the tumor and freezes it. The size of the tumor determines the number of applicators to freeze it completely (WHO, 2014). The applicators are then removed, and pressure is applied to stop bleeding. No suture is required, and bleeding is stopped by applying a bandage on the skin.  The physician must follow up the patient to determine the remission of the tumor.

In cryosurgery, the surgeon opens the patient and localize the lesion. The surgeon excises the tumor to the margin he can visualize. The intervening physician applies the applicator (Nitrogen liquid) to the margin. This kills the microscopic lesions that cannot be visualized and this enhance remission. In cryosurgery, cryotherapy is used as an adjuvant intervention. Its effectiveness is not understood well, but several types of research are underway to find its effectiveness.

In postoperative, the patient should be observed for adverse side effects. For patients undergoing the procedure in an outpatient setting, the patient should be accompanied by a relative and should not be allowed to drive (Bahn et al., 2012). Patients who are admitted should be observed for signs of infections, should be monitored for bleeding and pain management should be enhanced. Surgical wounds must be dressed and disinfected. Benefits of Cryotherapy

Cryotherapy has many benefits when compared to open surgery. It is a procedure that can be performed in two to three hours. It also requires less personnel to initiate as compared to open surgery. The recovery time following cryotherapy of liver and kidney tumor is shorter as compared to that of open surgery (WHO, 2014). A patient undergoing percutaneous cryotherapy requires a few hours of observation and may go home on the day of procedure as compared to open surgery where patients must be admitted for several days. Percutaneous cryotherapy is also less traumatic because the physician only makes one incision which limits damage to the adjacent tissues. Cryotherapy is cheaper with fewer adverse effects than open surgery. Cryotherapy also causes minimal scar tissue in the management of fibroadenomas in the breast of female and has no post-treatment calcifications as compared to other interventions. Cryotherapy by itself does not emit radiation, but the imaging techniques used may predispose the patient to radiation. The cryotherapy also decreases the cost the patient has to incur in the management of their condition.

Risks of Cryotherapy

Cryotherapy is a percutaneous procedure and bleeding may occur resulting from the puncture and freezing of organs such as kidney, liver, and kidney. It causes spontaneous bleeding to patients with acquired and inherited coagulopathy. The adjacent structures may occur during percutaneous cryotherapy especially when the guided imaging is not employed. When percutaneous cryotherapy is used for the treatment of hepatocellular carcinoma, the biliary tree can be injured. This will lead to jaundice and itchiness.  During kidney cryotherapy, the collecting system, and the ureters are sometimes damaged. The result is acute kidney failure which requires transplant (Hawkins, & Hawkins, 2016). Cryotherapy for prostate usually damages the rectum which is situated behind it.

Treatment of the gastrointestinal tract may lead to perforation. Perforation of the gut can lead to the contents of the abdomen spreading to the peritoneum. This may cause acute peritonitis which is life threatening. Cryotherapy near the diaphragm, fluid often accumulates in the pleural cavity leading to atelectasis.  Nerves injury may result during the intervention. This leads to loss of motor and sensory function of the affected nerve (Bahn et al., 2012). Complications related to the anesthetic agent may result, the worst being the cardiopulmonary failure. Radiation exposure from the imaging may predispose the patients to radiation associated malignancy and malformation, especially in pregnant women. Following cryotherapy of the prostate, impotence results from damage to nerves and urethral stricture is also a common complication.

Limitation of cryotherapy

Cryotherapy is an alternative therapy for cancer when surgical resection cannot be achieved, but little study has been done to support this. Cryotherapy is a localized intervention meaning it can be employed for specific tumors that are localized at a particular site. It cannot be applied for distant metastasis limiting its use. The intervening physician may miss microscopic tumor since they can only treat what they can visualize. The residue malignancy can act as a source for the spread of malignancy (Bahn et al., 2012). There are other alternatives that have been approved for the management of certain cancer that has proven effective. Having patients undergo the procedure especially for the management of cancer is an uphill task. Expertise in the field still lags behind since it is a new intervention in the United States of America.

Conclusion

Cryotherapy is a new biomedical practice that has been embraced in the United States of America. It is used in sports science to relieve acute pain for the athletes and footballers. It is also used in the management of skin conditions, in the management of both benign and malignant cancers. Cryotherapy is being used in many hospitals to manage the Intraepithelial Neoplastic of the cervix and management of prostate cancer where surgical intervention cannot be achieved. Despite the many limitations to the adaptation of the procedure, many types of research are underway to determine its effectiveness.

 

References

Bahn, D., de Castro Abreu, A. L., Gill, I. S., Hung, A. J., Silverman, P., Gross, M. E., … & Ukimura, O. (2012). Focal cryotherapy for clinically unilateral, low-intermediate risk prostate cancer in 73 men with a median follow-up of 3.7 years. European urology, 62(1), 55-63.

Hawkins, S. W., & Hawkins, J. R. (2016). CLINICAL APPLICATIONS OF CRYOTHERAPY AMONG SPORTS PHYSICAL THERAPISTS. International journal of sports physical therapy, 11(1), 141.

World Health Organization. (2014). WHO guidelines for treatment of cervical intraepithelial neoplasia 2-3 and adenocarcinoma in situ: cryotherapy, large loop excision of the transformation zone, and cold knife conization.

Bleakley, C. M., Bieuzen, F., Davison, G. W., & Costello, J. (2014). Whole-body cryotherapy: empirical evidence and theoretical perspectives. Open access journal of sports medicine, 5, 25-36.

Samrao, A., & Cockerell, C. J. (2013). Pharmacotherapeutic management of actinic keratosis: focus on newer topical agents. American journal of clinical dermatology, 14(4), 273-277.

 

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