This effective therapy can make a difference for both patient and practice.

It's an open secret that word-of-mouth referrals from satisfied patients is the primary source of new patients for most physicians. In many instances, patients refer others with similar conditions to their own physicians. And far and away the number one reason patients see a chiropractor is for pain.

Consequently, it is incumbent upon the practitioner to do whatever he can to ease the patient's suffering as quickly as possible, while at the same time correcting the cause of his/her misery. Unfortunately, this is not always easily accomplished because there are some people—a small percentage of one's practice—who are in such intractable pain (be it acute or chronic) that nothing seems to help. Visit after visit they complain that they're not feeling any better, or that they simply haven't "turned the corner" in their recovery. Naturally, this can be quite frustrating for both patient and doctor.

In a case such as this, the temptation to release or refer the patient prematurely is a common pitfall. Or the sufferer may just stop care altogether on their own. This can be very discouraging for the parties concerned and, understandably, can wreak havoc on the doctor's referral network. Moreover, his/her reputation as a healer could suffer as well, since people with poor results have little reason to refer others. (It's been said that a satisfied patient will tell two or three others about a product or service, while a dissatisfied patient will relate their pitiful plight to 12 other people.)

Long-term Cryotherapy Can Help

If just one intractable pain victim can be saved each month by long-term cryotherapy (LTCT), then that's one less "hopeless" case we've lost and one more satisfied patient we've gained! Furthermore, once the sufferer of persistent pain can see "light at the end of the tunnel," their hopes are raised accordingly and they are likely to hang around long enough for chiropractic to correct the underlying cause of their condition. It's a "moment of truth" for both patient and doctor.

How LTCT Works

Whenever soft-tissue trauma occurs, it results in inflammation (infections may also cause inflammation), which is characterized by heat, redness, swelling, and pain. These are also known as the cardinal signs of inflammation, which can often cause circulatory stasis and loss of function. Ironically, because these four cardinal signs always occur together, they cannot exist alone. The removal of one removes the other three signs.

So, if we remove the heat, then the swelling, redness, and pain will all disappear together. The logical way to reduce heat is by absorbing the calories out by the use of cold therapy in an effective, safe, convenient, low-cost manner. The degree of intensity of the four cardinal signs of inflammation is directly proportional to the severity of the injury. Thus, the more severe the injury, the more calories must be absorbed by the cold therapy to reduce the pain. When tissue is cooled, there is a contraction of fluid volume, thereby relieving the pain that is caused by the pressure that the swelling exerts on the nerve endings.¹

In addition to its analgesic effects, LTCT also speeds up healing. Since cold applications always (not just sometimes) reduce fluid volume, it can help with phagocytic activity. Boyd's Textbook of Pathology states that macrophages and leucocytes (phagocytes) travel along fibrin pathways, but cannot "swim" in fluids between the fibrin.¹ It would seem that with the reduction of fluid between the fibrin network, phagocytic activity could cover the entire injured area in less time and assist in a speedier recovery.

How Safe Is LTCT?

The big fear that doctors and patients have is the possibility that frostbite (skin freezing) will occur when cryotherapy is used. Using ice and water in an ice pack is absolutely safe because it reduces skin temperature automatically to only 34°F or above, and maintains a temperature range between 34°F and 40°F until all the ice is melted.

Frostbite occurs only when the skin temperature is brought down to 32°F or below. For this reason, using gel packs is not safe because frostbite may occur when they are used one after another on the same area. Gel packs used this way can reduce skin temperatures down far below the freezing point of 32°F.

A patient may say, "Well, if I place a towel under the gel pack, won't that be all right, Doc"? Then that defeats its ability to penetrate deep into the body, because the towel insulates the gel—especially because gel packs last for less than

20 minutes and have no circulation within the pack. When the gel adjacent to the towel and the skin warms up, it becomes ineffective to cool any longer. LTCT, using ice and water, takes temperatures down to ideal therapeutic levels and can be used for hours (not minutes, which are ineffective) to produce remarkable results.

How Long Should LTCT Be Applied?

Most doctors of chiropractic were taught in college the prevailing theory that ice should not be applied for more than 20 minutes to strains, sprains, or inflammations. Yet in dealing with intransigent or deep spinal pain, I have found that the results of such a brief session are much less than the "alpha and omega" of cryotherapy effectiveness.

It has been my experience that the successful resolution of serious pain requires the application of ice therapy for hours, rather than minutes, to penetrate deep into the spine. So, when LTCT is applied for hours, it works amazingly well. The magic occurs when the cryotherapy time is increased to the dictates of the intensity of the pain! The more entrenched and severe the pain, the longer the ice therapy needs to be applied. Thus, the acronym LTCT was coined.

A good example of deep pain (2 to 3 inches) is when an intervertebral disk (IVD) bulges and compresses a spinal nerve root (SNR). Injury to the IVD generates heat by traumatic friction, resulting in inflammation (often called a hot disk), which in turn increases the internal pressure of the IVD. For example, increase the temperature of an automobile tire and the internal pressure (turgor) of the tire will increase several pounds.

In light of this, when LTCT reduces the temperature inside the disk (nucleus pulposus) and subsequently contracts it, this then reduces the internal turgor of the IVD, thereby removing some pressure off the SNR. Pain is relieved proportionally to the amount of LTCT that is applied and the amount of contraction that it produces.

Why LTCT Is Most Effective

Keeping in mind that the IVD is 2 to 3 inches deep from the surface, cold pack therapy must be applied for hours at 34°F to 40°F on the surface to reduce internal temperatures 2 to 3 inches deep approximately 10°F or less. This 10° reduction must be continued (usually 6 hours or more) to effect slight contraction of the IVD fluid, which will reduce some pressure on the SNR. This spells pain relief that cannot be obtained in any other physiological way.

By absorbing caloric heat out of swollen (inflamed) tissues, joints, muscles, ligaments, and nerves, as well as acute, subacute, or chronic inflammation, will all respond to proper and persistent use of LTCT applications. Furthermore, it would be an especially effective therapy to use immediately after an injury, thereby curtailing or preventing the post-traumatic inflammatory swelling in the first place.

Yet, by the time many patients seek care for intractable pain, the inflammatory process is so far along and well-entrenched that brief spells of ice therapy just won't accomplish the goal of mitigating the patient's pain. What's worse, an angry, swollen, painful joint is not very amenable to chiropractic technique, thereby delaying correction.

Moreover, the disk, when contracted by the cold therapy, is easier to manipulate by chiropractic methods. That is, it is much easier to press a bulge inward on an automobile tire if we first partially deflated it! In fact, when a disk has been attenuated by cold therapy for 4 or 5 days, it blazes a trail for easier manipulation, for it is almost always associated with increased audible releases when the disk replacement occurs.

Seven Ways LTCT Reduces Pain and Promotes Healing

1. Reduces or removes the four cardinal signs of inflammation.
2. Tissues cooled with ice packs down to 34°F to 40°F contract the volume of tissue swelling (fluids).
3. Reduction of fluid volume reduces painful pressure on nerve endings.
4. Speeds healing by increasing macrophage activity.
5. Ice packs containing only ice and water are safe. So safe that, if they are applied to the skin constantly for a year, there would be no frostbite. Contraindications are few (such as metal inserts in the body, using alcohol or any other chemical in the ice pack, using ice packs with excessive pressure—all of which reduce temperatures below 32°F).
6. Ice and water cold packs can last for hours, and safely penetrate deeply into the spine and core of the body.
7. Wherever inflammation exists in the body, cryotherapy can help.

LTCT Can Be a Powerful Healing Weapon

The bottom line is, LTCT can give every DC the power to control nearly every kind of pain that occurs in his/her practice. This can be a very satisfying feeling of practice control, not unlike that which MDs have in using narcotics. However, this gives chiropractic the best of all possible worlds, because the DC can provide pain relief without the patient becoming addicted to drugs. It engenders a "whole new ball game" of higher levels of chiropractic results.

Adjunctive LTCT treatment for your patients could very well make the difference between blessed recovery or continued therapeutic recalcitrance. And the far-reaching effects of raising your success rate can, needless to say, do wonders not only for mankind but for your practice as well. Some would call that a win-win situation!

How Does a DC Implement the Full Potential of LTCT?

It's quite simple: Prescribe long-term use of cold pack applications for your patients who are in pain. I have found that the most effective way (although very untechnical) to use cold packs is by using ice and water alone in an 11-inch ice bag. The use of a 6-inch lumbar belt can be used for easy application to your patient's low back.

Application to the cervicals can be convenient also, by using a towel (folded longways in thirds, draped over the neck with an ice pack underneath. The two ends of the towel are connected in front above the chest with two or three rubber bands). The ice pack will last approximately 2 hours and has to be recharged with more ice for extended treatment.

The best ice bag (cap) I have found is the blue rubber-ish textured type made by the Faultless Co. The company meant what the name implies when it named the product Faultless. The ice cap almost never leaks and can last 10 years or more. The 11-inch Faultless ice cap can be purchased at nearly any drugstore or wholesale at Bodyline Comfort Systems and sold to your patients.

John W. Fiore, DC, is founder of Bodyline Comfort Systems. He has been in continuous practice for 37 years and has used different levels of cryotherapy for 27 years. He can be reached at .

Reference

1. Boyd W. Textbook of Pathology, 5th ed. Philadelphia: Lea & Febiger; 1947:106,114.