1 DEVELOPMENTS IN CRYOTHERAPYAss. Prof. Agata Stanek MD, PhD President of Polish Society of Cryotherapy Department and Clinic of Internal Diseases, Angiology and Physical Medicine in Bytom of Medical University of Silesia in Katowice EUROPEAN CRYOGENICS DAYS, GENEVA

2 COLD - HISTORY OF THERAPEUTICAL APPLICATON2500 B.C. – in Egypt- cold exerted an anti-inflammatory effect and alleviated injury pain; in V B.C. Hippocrates used cold to decrease swelling, bleeding and pain;

3 COLD - HISTORY OF THERAPEUTICAL APPLICATONin 1883 a Polish physicists Karol Olszewski and Zygmunt Wróblewski executed the first condensing of nitrogen and oxygen;

4 COLD - HISTORY OF THERAPEUTICAL APPLICATONin 1978 T. Yamauchi in Japan – created whole-body cryotherapy; for the first time in the world he applied whole-body cryotherapy in the treatment of patients with rheumatoid arthritis

5 COLD - HISTORY OF THERAPEUTICAL APPLICATONin 1982 R. Fricke in Germany- used whole- body cryotherapy for the first time in Europe;

6 COLD - HISTORY OF THERAPEUTICAL APPLICATONCryotherapy in Poland: In 1983 – Z. Zagrobelny – Department of Physiotherapy of University School of Physical Education in Wroclaw – local cryotherapy was applied for patients first time in Poland;

7 COLD - HISTORY OF THERAPEUTICAL APPLICATONCryotherapy in Poland: 1989 Polish cryochamber (second in Europe, third in the world) Zbigniew Raczkowski –Institute of Low Temperatures and Structural Investigations of the Polish Scientific Academy in Wroclaw; the creator of the first Polish cryochamber

8 Cryogenic temperatures in medicineMODERN CRYOMEDICINE Cryogenic temperatures in medicine

9 CRYOTHERAPY CRYOSTIMULATION CRYOSURGERY LOCAL CRYOSTIMULATIONWHOLE-BODY CRYOSTIMULATION

10 CRYOSURGERY

11 Cryosugery - interruption of the continuity of tissues as a result of freezing with a view to their removal or destruction.

12 CRYO-S MINI Cryoflex device for cryosurgery

13 Cryosurgical treatment with usage of spray probe

14 CRYOTHERAPY- DEFINITIONThe use of extremely low temperatures (below –100°C) applied for a short time (2-3 minutes) to stimulate physiological reactions in the human body, in order to achieve more effective pharmacological treatment and kinesiotherapy. Sieroń A., Cieślar G., Stanek A. (eds). Cryotherapy. alpha-medica press, Bielsko-Biała, 2010 Stanek A., Cieślar G., Sieroń A. Therapeutic aplication of cryotherapy in clinical practice. Balneol. Pol., 2007, 49, 1, 107, Podbielska H., Stręk W., Biały D. (eds). Whole-body cryotherapy. Acta of Biomedical Engineering. Indygo, Zahir Media, Wroclaw, 2007 Zagrobelny Z.(ed). Whole-body and local cryotherapy. Urban & Partner, Wroclaw, 2003

15 LOCAL CRYOTHERAPY (CRYOSTIMULATION-HYPERBARIC GASEOUS LOCAL CRYOTHERAPY)

16 LOCAL CRYOTHERAPY application of the cold to a selected part of the human body.

17 ACCORDING TO THE KIND OF COOLING MEDIUM LOCAL CRYOTHERAPY IS DIVIDED INTO:Cryotherapy with liquid nitrogen. Cryotherapy with carbon dioxide.

18 CRYO -T ELEPHANT devices for local cryotherapy-cooling medium liquid nitrogen (METRUM CRYOFLEX)

19 CRYO -T (METRUM CRYOFLEX) device for local cryotherapy-cooling medium liquid carbon dioxide

20 KRIOPOL R60 CREATOR

21 WHOLE-BODY CRYOTHERAPYApplication of cryogenic temperatures for a short time (1-3 minutes) on the entire body of the patient. Whole-body cryotherapy is performed in cryochambers

22 WHOLE-BODY CRYOTHERAPYAntechamber: acclimatisation to cryogenic temperature, exposure duration 60 seconds, temperature -60°C. Proper chamber: exposure duration 2-3minutes, temperature below -110°C. The exposure duration depends on individual cryogenic temperature tolerance. Sieroń A., Cieślar G., Stanek A. (eds). Cryotherapy. alpha-medica press, Bielsko-Biała, 2010 Stanek A., Cieślar G., Sieroń A. Therapeutic aplication of cryotherapy in clinical practice. Balneol. Pol., 2007, 49, 1, 107, Podbielska H., Stręk W., Biały D. (eds). Whole-body cryotherapy. Acta of Biomedical Engineering. Indygo, Zahir Media, Wroclaw, 2007 Zagrobelny Z.(ed). Whole-body and local cryotherapy. Urban & Partner, Wroclaw, 2003

23 CRYOTHERAPY CHAMBER –WROCŁAW TYPE(CREATOR)

24 TWO - CHAMBER SYSTEM Proper chamber Temp. -110° C Antechamber

25 CRYOCHAMBER WITH COLD RETENTION (CRYOFLEX METRUM)

26 EXAMPLE OUTFITS FOR WHOLE - BODY CRYOTHERAPY

27 ANALGESIC EFFECT Endocrine system- increased beta-endorphins secretion; Neuronal system - functional exclusion of sensory receptors and their junctions with proprioceptors; decreased nerve transmission in sensory fibres, reduction the activity of free nerve endings, raising the pain threshold, over-ride the pain sensation - known as the pain gate theory; Wawrowska A.: Wpływ ogólnoustrojowej krioterapii organizm osób zdrowych i chorych reumatycznych ze szczególnym uwzględnieniem stężeń wybranych hormonów, beta-endorfin, 6-ketoPGF1. Praca Dokorska AWF, Wrocław 1992. Bauer J., Skrzek A.: Fizjologiczne podstawy krioterapii. Acta Bio-Opt. Inform. Med.., 1997,3,(2-4), Sieroń A., Rykaczewska-Czerwińska M., Klimkiewicz T., Jakrzewska H., Jagodziński L., Birkner E., Wiśniowska B., Plech A. Antinociceptive effect in rats induced by the cooling of their whole body. Acta Bio-Opt.Inform.Med., 2002,8, ;

28 ANALGESIC EFFECT Metabolic action (among others decreased concentrations of histamine and lactate in inflammatory changed tissues). Sieroń A., Cieślar G., Stanek A. (eds). Cryotherapy. alpha-medica press, Bielsko-Biała, 2010 Stanek A., Cholewka A., Cieślar G., Rosmus-Kuczia I., Drzazga Z., Sieroń A. Estimation of analgesic action of whole-body cryotherapy in patients with ankylosing spondylitis..Fizjoter. Pol., 2011, 1, 4, Zagrobelny Z.(ed). Whole-body and local cryotherapy. Urban & Partner, Wroclaw, 2003

29 NEURO-MUSCULAR EFFECTreduction of nerve transmission and reactivity of peripheral sensomotor nerve endings  decreased muscle tone; increased muscle power; Bilińska M., Rudkowska-Brzecka A., Marytnów R., Brzecki A.: Badania elektromiograficzne w ocenie siły mięśniowej po krioterapi u chorych z reumatoidalnym zapaleniem stawów. Przegl. Lek., 1993, 50, (1-2), Schroder D., Anderson M.: Kryo-und-Theromtherapie: Grundlagen und praktische Adwendung.Harausgegeben von Bernd Gaupel, Gustav Fischer verlag, Stuttgarrt-Jena-New York 1995.

30 ANTIOEDEMATOUS EFFECTarterial hyperemia of periarticular oedemas, increased capillary filtration, improvement of lymphatic vessels patency draining intercellular space. Gregorowicz H., Zagrobelny Z. Krioterapia ogólnoustrojowa wskazania i przeciwwskazania, przebieg zabiegu i jego skutki fizjologiczne i kliniczne. Acta Bio-Opt. Inform. Med., 1998, 4, Kalmus P., Włodarczyk K., Pinkowska I., Piotrowska E., Szulicka A. Wyniki leczenia reumatoidalnego zapalenia stawow zabiegami krioterapeutycznymi i peloidowymi. Baln. Pol.,1999, 41,83-91.

31 ANTIOEDEMATOUS EFFECTcryogenic temperatures accelerate lymphatic flow but they do not influence lymph formation the lymphatic flow acceleration is long lasting but it appears only at the end of the exposure cycle (10 daily exposures) Sieroń A., Pastuszka A., Marniok B., Wiśniowska B., Jagodziński L., Ślusarczyk K., Cieślar G., Stanek A. Influence of low temperatures on lymph formation and flow velocity in mice. Thermology Int.,2004,14,

32 ANTIINFLAMMATORY EFFECT inflammatory parameters: ESR (erythrocyte sedimentation rate), CRP (C-reactive protein), seromucoid, IL-2,IL-8,IL-10, sICAM; Stanek A., Cieślar G., Strzelczyk K., Kasperczyk S., Wiczkowski A., Birkner E., Sieroń A.: Influence of cold on inlammatory markers in patients with ankylosing spodylitis and healthy volunteers. Polish Journal of Environmental Study, 2010,19,1, Banfi G., Melegati G., Barassi A., Dogliotti G., d’Eril G., Dugue B., Corsi M. Effects of whole-body cryotherapy on serum mediators of inflammation and serum muscle enzyme in athtes. J.Thermal Biol., 2008, 34,55-59.

33 ANTIINFLAMMATORY EFFECTbeneficial influence on the prooxidant-antioxidant balance Stanek A. Influcence of whole-body cryotherpy on antioxidant status in patients with ankylosing spondylitis. Thesis, Medical University of Silesia, 2004 Lubkowska A., Chudecka M., Klimek A., Szyguła Z., Frączek B.: Acute effect of a single whole-body cryostimulation on prooxidant-antioxidant balance in blood of healthy, young men. J Thermal. Biol., 2008, 33, Mila-Kierzenkowska C., Wozniak A., Wozniak B., Drewa G., Rakowski A., Jurecka A., Rajewski R. Whole-body cryostimulation in kayaker women: a study of the effect of cryogenic temperatures on oxidative stress after the exercise. J. Sports Med. Phys. Fitness, 2009, 49, (2),

34 IMMUNE SYSTEM cellular and humoral immunity  prostaglandins and cytokins; number and percentage of lymphocytes: CD3, CD4, CD8, CD19, CD56(NK); Zagrobelny Z., Halawa B., Kuliczkowski K., Frydecka I., Grgorowicz H.: Wpływ ogólnoustrojowej krioterapii w komorze niskotemperaturowej oraz leczenia ruchem na subpopulacje limfocytów we krwi obwodowej u chorych na chorobę zwyrodnieniową stawów i reumatoidalne zapalenie stawów. Reumatologia, 1996, 34,

35 HORMONAL SYSTEM - adrenaline, noradrenaline, cortisol, B- endorphine, testosterone (in males);  thyrothrophic hormone, thyroid hormones, growth hormone, follicular hormone, luteinizing hormone and 6-ketoPGF1 (prostaglandin metabolite causing vasodilatation effect of blood vessels) Wawroska A.: Wpływ ogólnoustrjowej krioterapii na organizm osób zdrowych i chorych reumatycznych ze szczególnym uwzględniem stężeń wybranych hormonów, beta-endorfin, 6-ketoPGF1. Praca Dokorska AWF, Wroclaw 1992. Smolander J., Leppäluoto J., Westerlund T., Oksa J., Dugue B., Mikkelsson M., Ruokonen A. Effects of repeated whole-body cold exposures on serum concentrations of growth hormone, thyrotropin, prolactin and thyroid hormones in healthy women. Cryobiology, 2009, 58, (3),

36 CIRCULATORY SYSTEM MICROCIRCULATION MACROCIRCULATION

37 MICROCIRCULATION I phase: - contraction of precapillary sphincters   skin precapillary flow; - opening of arteriovenous anastomoses  oxygenated blood flow back through veins to the left atrium of the heart; Bauer J., Skrzek A. Fizjologiczne podstawy krioterapii. Acta Bio-Opt.Inform.Med., 1997,3, Gregorowicz H.: Wpływ krioterapii ogólnoustrojowej na wybrane wskaźniki hemodynamiczne i wentylacji płuc w schorzeniach reumatycznych. Praca Doktorska AM, Wrocław, 1992.

38 MICROCIRCULATION II phase: - vasodilatation of capillary vessels,closure of arteriovenous anastomoses,  hiperperfusion of tissues  oxygen supply to tissues with inflammatory changes,  lactate and histamine concentrations  pain reduction Bauer J., Skrzek A. Fizjologiczne podstawy krioterapii. Acta Bio-Opt.Inform.Med., 1997,3, Gregorowicz H.: Wpływ krioterapii ogólnoustrojowej na wybrane wskaźniki hemodynamiczne i wentylacji płuc w schorzeniach reumatycznych. Praca Doktorska AM, Wrocław, 1992.

39 MACROCIRCULATION  blood pressure, heart rate, left ventricular contractility; in literature there are no cases of arrhythmias, electrocardiographic symptoms of myocardial ischemia; Jagodziński L., Cieślar G., Stanek A., Puszer M., Bilska A., Wiśniowska B., Romuk E., Skrzep-Poloczek E., Birkner E., Sieroń A.: Ocena frakcji wyrzutowej lewej komory serca u pacjentów z zesztywniającym zapaleniem stawów kręgosłupa poddanych krioterapii ogólnoustrojowej. Balneol. Pol., 2003, 45, (3-4), Jonderko G., Końca A., Rosmus-Kuczia I., Nowicki L.: Wpływ krioterapii miejscowej gazem chłodzącym i lodem na elektrokardiogram i ciśnienie tętnicze krwi u chorych na reumatoidalne zapalenie stawów. Ann.Acad. Med.Siles., 1991,24, Zagrobelny Z., Halawa B., Negrusz-Kawecka M., Spring A., Gregorowicz H., Wawrowska A., Rozwadowski G.: Zmiany hormonalne i hemodynamiczne wywołane schładzeniem całego ciała chorych na reumatoidalne zapalenie stawów. Pol. Arch. Med. Wewn., 1992,87,34-40.

40 AND ALSO….

41 WHOLE – BODY CRYOTHERAPHYbeneficial influence on the psyche (decreased level of fear, anxiety, excitability; increased perception). Rymaszewska J., Biały D., Zagrobelny Z., Kiejna A. The influence of whole-body cryotherapy on mental health. Psychiatr.Pol., 2000,34,64-653; Rymaszewska J., Ramsey D., Chładzińska-Kiejna S. Whole-body cryotherapy as adjunct treatment of depressive syndrome and anxiety disorders. Arch. Immunol. Ther. Exp.,2008,56,63-68.

42 WHAT MORE

43 Cryotherapy prior to kinesiotherapy facilitates the intensification of training and its duration severalfold. Sieroń A., Cieślar G., Stanek A. (eds). Cryotherapy. alpha-medica press, Bielsko-Biała, 2010 Stanek A., Cieślar G., Sieroń A. Therapeutic aplication of cryotherapy in clinical practice. Balneol. Pol., 2007, 49, 1, 107, Podbielska H., Stręk W., Biały D. (eds). Whole-body cryotherapy. Acta of Biomedical Engineering. Indygo, Zahir Media, Wroclaw, 2007 Zagrobelny Z.(ed). Whole-body and local cryotherapy. Urban & Partner, Wroclaw, 2003

44 WHY ?

45 Reduced stimulus thresholdCryotherapy Reduced stimulus threshold Analgesia Reduced tendon reflexes Reduced pain Reduced muscular tone Prolonged relaxation Improvement of motion range Physical rehabilitation (kinesiotherapy) Knight K.L. Cryotherapy in sport injury management, Human Kinetics: Champaingn, 1995.

46 CRYOTHERAPY - clinical indications:I. Disorders of motion system II. Neurological system disorders III. Wellness Depressive syndrome V. Sports medicine

47 DISORDERS OF MOTION SYSTEM:inflammatory diseases of motor system (f.e. reumatoid arthritis, ankylosing spondylitis); degenerative diseases of joints and the spine; inflammatory lesions of the joints of metabolic origin (e.g. gouty diathesis); Sieroń A., Cieślar G., Stanek A. (eds). Cryotherapy. alpha-medica press, Bielsko-Biała, 2010. Stanek A., Cholewka A., Gaduła J., Drzazga Z., Sieroń A., Sieroń-Stołtny K.. Can whole-body cryotherapy with subsequent kinesiotherapy procedures in closed type cryogenic chamber improve BASDAI, BASFI, some spine mobility parameters and decrease pain intensity in patients with ankylosing spondylitis? BioMed Res Int 2015, Vol , Article ID , 11 pages Zagrobelny Z.(ed). Whole-body and local cryotherapy. Urban & Partner, Wroclaw, 2003

48 DISORDERS OF THE MOTION SYSTEM:posttraumatic and overloading lesions, discopathy, osteoporosis, fibromyalgia syndrome; Sieroń A., Cieślar G., Stanek A. (eds). Cryotherapy. alpha-medica press, Bielsko-Biała, 2010 Stanek A., Cieślar G., Sieroń A. Therapeutic aplication of cryotherapy in clinical practice. Balneol. Pol., 2007, 49, 1, 107, Podbielska H., Stręk W., Biały D. (eds). Whole-body cryotherapy. Acta of Biomedical Engineering. Indygo, Zahir Media, Wroclaw, 2007 Zagrobelny Z.(ed). Whole-body and local cryotherapy. Urban & Partner, Wroclaw, 2003

49 NEUROLOGICAL SYSTEM DISORDERS:diseases of the central nervous system with muscle spasticity multiple sclerosis radicular syndromes diseases of the peripheral nervous system

50 SPORTS MEDICINE : The benefits observed are: reduction of painincrease in muscle strength inhibition of inflammatory processes reduction in the regeneration phase reduction of posttraumatic treatment enhancement of sports performance overall faster return to training Biały D., Zimmer K., Zagrobelny Z. Krioterapia ogólnoustrojowa w sporcie. Med.Sport.,1999, 15,21-24. Swenson C., Sward L., Karlsson J. Cryotherapy in sport medicine. Scand. J. Med.Sci. Sport., 1996,6,

51 Future development

52 FUTURE CRYOTHERAPY - health and well - beingMore and more frequently cryotherapy is used to improve health, harden and revitalize the body and prevent stress-related diseases and their consequences Stanek A., Sieroń A. Contemporary whole-body cryotherapy in biological renewal. Ann. Acad. Med. Siles., 2012, 66, 4, 64-70

53 FUTURE - SKIN Whole-body cryotherapy helps to reduce the appearance of cellulite and loose skin as a result of aging, weight lost, post liposuction as well as prevents wrinkles.

54 CELLULITE - BEFORE AND AFTER WHOLE-BODY CRYOTHERAPY

55 STRICT CONTRAINDICATIONS TO CRYOTHERAPY:cold intolerance, cryoglobulinemia, cryofibrinogenemia, Raynaud’s phenomena, cold urticaria, Sieroń A., Cieślar G., Stanek A. (eds). Cryotherapy. alpha-medica press, Bielsko-Biała, 2010 Stanek A., Cieślar G., Sieroń A. Therapeutic aplication of cryotherapy in clinical practice. Balneol. Pol., 2007, 49, 1, 107, Podbielska H., Stręk W., Biały D. (eds). Whole-body cryotherapy. Acta of Biomedical Engineering. Indygo, Zahir Media, Wroclaw, 2007 Zagrobelny Z.(ed). Whole-body and local cryotherapy. Urban & Partner, Wroclaw, 2003

56 STRICT CONTRAINDICATIONS TO CRYOTHERAPY:venous thromboemolism, hypothyreosis, local disorders of blood supply, Sieroń A., Cieślar G., Stanek A. (eds). Cryotherapy. alpha-medica press, Bielsko-Biała, 2010 Stanek A., Cieślar G., Sieroń A. Therapeutic aplication of cryotherapy in clinical practice. Balneol. Pol., 2007, 49, 1, 107, Podbielska H., Stręk W., Biały D. (eds). Whole-body cryotherapy. Acta of Biomedical Engineering. Indygo, Zahir Media, Wroclaw, 2007 Zagrobelny Z.(ed). Whole-body and local cryotherapy. Urban & Partner, Wroclaw, 2003

57 STRICT CONTRAINDICATIONS TO CRYOTHERAPY:considerable anemia, claustrophobia, cachexia, hypothermia, cancer disease Sieroń A., Cieślar G., Stanek A. (eds). Cryotherapy. alpha-medica press, Bielsko-Biała, 2010 Stanek A., Cieślar G., Sieroń A. Therapeutic aplication of cryotherapy in clinical practice. Balneol. Pol., 2007, 49, 1, 107, Podbielska H., Stręk W., Biały D. (eds). Whole-body cryotherapy. Acta of Biomedical Engineering. Indygo, Zahir Media, Wroclaw, 2007 Zagrobelny Z.(ed). Whole-body and local cryotherapy. Urban & Partner, Wroclaw, 2003

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