HILOTHERAPY ® works!

The new standard. Postsurgical. Post­traumatic.

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Preliminary Note

Thousands of years of experience have proven that the cold can heal!

2400 years ago, Hippocrates‘ teachings told of the excellent effect of snow and ice on the formation of hematoma, swelling and pain.

Everybody knows the beneficial effect of localized cold treatments from their own experience.

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The therapeutic effects of the cold

reduction acidosis

Congelation, paralysis losses

(only <10°C)

short­term vaso­

dilatation

mid­term vaso­

constriction

reduction circulation

faster mobilisation rehabil.

adapation decreased

O2 availability

reduction muscle­ spasms

Desensiti­ sation

nociceptors

reduction pain­

mediators

reduction swelling,

haematoma, oedema

reduction inflmmatory­ reactions exsudat

reduction metabolic speed

reduction collagenase activity

local

hypo­

thermia 1:Schaube 16:Abramson D.I. et al. 17:Fruhstorfer H. 18:Kellet J. 19:Hartviksen K.

8:McMaster et al. 2,3:Knight K.L. 4:Liman et al. 5:Thorsson et al. 11:Svanes K. 14:Wright J.G. et al. 15:Matsen F.A. et al

6:Löffler et al. 39:van der Meulen J.C.H.

9:Wright J.G. et al. 13:Irving et al.

8:McMaster et al. 10,11:Svanes K. 12:Farry et al. 13:Irving et al. 15:Matsen F.A. et al

7:Harris et al.

2:Knight K.L.

2:Knight K.L. 20:Drez D. et al. 21:Collins K. et al. 22:Basset F.H.,III; et al.

13:Irving G.A. et al. 23:Spence J.D. et al. 26:Pässler H. et al. 27:Schröder D. et al. 37:Esclamado R.M. et al.

17:Fruhstorfer H. 18:Kellet J.

24:Kern H. 25:Ott R. et al. 26:Trnavsky G.

Positive Effect

Negative Effect

8:McMaster et al. 9,14:Wright J.G. et al. 15:Matsen F.A. et al. 11:Svanes K. 35:Coté D. et al. 36:Eston R. 34,38: Meeusen R.

à see references (literature)

6:Löffler et al. 2:Knight K.L. 8:McMaster et al. 11:Svanes K. 13:Irving et al. 15:Matsen F.A. et al.

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From trauma to hypoxia damage

ischaemia

lack of O2

acidosis

destruction of cell membrane cell death

release of lysomal enzymes, proteins

inflamation oedema

haematoma pain

post­operative, traumatic reactions

reduction of antioxidant enzymes

free radicals

rise in colloid­ osmotic pressure

hypoxia

Ischaemia Injuries and operation procedures cause edema and bleeding, which affect the provision of oxygen and

nutrients to the tissue. (Ischaemia).

Vasodilatation Therefore the oxygen partial pressure of blood causes a local

vasodilatation which supports blood with more oxygen but at the

same time increases development of hematoma and edema.

Decay The resultant acidosis brings cell decay and the freeing of proteins. The ability of the proteins to bind

larger amounts of fluid is seen as the trigger for the formation of edema.

Antidote Cold treatment reduces the metabolism and circulation and leads, by means of inhibiting the local

inflammatory reaction, to a reduction of post­traumatic swelling.

(see the next slides)

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ischaemia

lack of O2

acidosis

destruction of cell membrane cell death

release of lysomal enzymes, proteins

inflammation oedema

haematoma pain

post­operative, traumatic reactions

reduction of antioxidant enzymes

free radicals

rise in colloid­ osmotic pressure

hypoxia

Hilotherapeutic effects

Slower metabolism A drop in temperature of 10°C reduces the metabolic speed by

about 50%. This reduces the oxygen demand and adapts it to the post­traumatic, reduced local oxygen supply in the tissue. In comparison, an increase of plus 3°C leads to a fourfold increase of the enzyme activities, e.g. collagenese.

Every injury results in a comparable inflammatory over warming.

Reduced tissue damage Local hypothermia affects a reduction of the hypoxia damage (caused by ischaemia) in that it interrupts the

circulus vitiosus due to lack of oxygen, acidosis, destruction of the cell membrane and death of the cell and moreover, slows down the activity of the lysomal enzymes (released from the dead cells).

Reduced swelling The result is a lower concentration of free cell parts (primarily proteins) and less water deposit in tissue by lowering colloid osmotic

pressure combined with the normally positive capillary filtration pressure.

Immediate analgesic effect Less release of pain producing substances occurring naturally in the body (mediator)

Biochemical and physical desensitization of nociceptors plus lowering of neural transmit rapidity.

Quicker recovery During the cold therapy, the healing of the wound is slowed as well as the remaining metabolism

without this having a negative effect on the completion of the wound healing. In fact due to the lesser degree of tissue damage, the cold therapy leads to a quicker recovery.

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Flannels

Frozen peas

Gel packs

Ice compresses

Ice bucket system

Ice cubes/ broken ice

ICE

• Aggressive cold treatments ­ can seriously damage skin and tissue (frostbite/

paralysis)

­ in combination with a short­term application, these ALWAYS lead to a reactive hyperemia

• The temperature cannot be ­ regulated ­ Constant

• The coolant has to be replaced regularly

• Increased burden on the health care workers

The problems with traditional coolants

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The problems with traditional coolants

• At below 15°C lymphatic drainage is disturbed

• At below 10°C the following is disturbed: ­ the proprioception ­ the creation of fibroblasts ­ the microcirculation

• At below 5°C ­ the nerves no longer conduct any impulses

Flannels

Frozen peas

Gel packs

Ice compresses

Ice bucket system

Ice cubes/ broken ice

ICE

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The Solution: Isothermal* HILOTHERAPY ®

• Worldwide the most modern Thermotherapy.

• Controlled temperature regulation to the degree from +10°C to +30°C.

• Anatomically­adapted cuffs for every part of the body.

• Broad indication spectrum.

• Easy to use.

• Long­term therapy requiring little effort from health care workers.

* From the Greek: ísos = constant; thermós = warm, hot. Isotherm describes changes of condition which occur at a constant temperature.

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Hilotherapy Effects

• Primary ­ Falling of skin and tissue temperature ­ Reduction of the metabolic processes ­ Adaptation to the oxygen and substrate needs ­ Vasoconstriction

• Secondary ­ Reduction of the tendency to swelling ­ Reduction in the formation of hematoma ­ Inhibits the inflammatory reaction ­ Soothing and pain­killing

• Other ­ Reduced lymphatic production ­ Increase of the venal compression/pressure ­ Relaxation of muscles ­ Decreased nerve impulse speed ­ Higher viscosity of tissue and synovia

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Indications for HILOTHERAPY ®

• Surgery ­ Micro­surgery ­ Plastic Surgery ­ Vascular Surgery ­ Orthopaedic & Bone Surgery ­ Oral and Maxillofacial surgery ­ Implantology ­ general post­operative wound healing

• Sport and other injuries ­ Sprains, muscle strain, myorrhexis, luxation, tendon

strain ­ Effusions of blood (treament of haemophiliacs) ­ Edema

• Functional Rehabilitation ­ Improvement of mobility ­ Pain relief ­ Relaxation of the muscles

• Rheumatic Illnesses ­ Inflammatory rheumatism ­ Algodystrophy­Syndrome ­ Ischias

• General ­ Fever ­ Migraines and stress­related headaches

• Traumatology / Orthopaedics

• Oral and Maxillofacial Surgery

• Ear, Nose and Throat Medicine

• Plastic / Aesthetic Surgery

• Physiotherapy / Rehabilitative Medicine

• Sports Medicine

• Dermatology

• Rheumatology

• Emergency Medicine

Range of Applications Medical Sectors

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Exemplary cuff use

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Cooling with HILOTHERAPY ®

• Both patients have received a face­lift (at a medical congress in Sylt/Germany).

Post­operative treatment with a traditional cold pack.

Post­operative HILOTHERAPY® treatment.

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Intra­operative

Post­operative (24hrs)

• Histologically­controlled excision of a basaloma on the left upper lid

• Much swelling in post­operative state, impossible to open the lid

• After 24 hours of HILOTHERAPY ® only moderate swelling remains with a free upper lid movement

Cooling with HILOTHERAPY ®

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Pre­operative

• Calcaneus comminuted fracture with long­ lasting swelling, inhibiting surgery

• After two days of HILOTHERAPY ® at 18°C surgery was possible, trouble free wound closure

• Little postoperative swelling and less need for analgesics due to HILOTHERAPY ® lasting several days

Cooling with HILOTHERAPY®

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Cooling with HILOTHERAPY®

This picture shows a patient 24 hours after the operation.

• Parkklinik Weißensee, Prof. Dr. Behrbohm

• HILOTHERAPY ® after rhinoplasty • Long­term application at 18°C

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• Polytrauma provision with HT 01 • The intensive care health workers

noticed ­ an extraordinarily quick receding of the

swelling (genital 50% within 24 hrs!), ­ good reaction of the body temperature ­ improved ability to patients‘ positioning as

a result of less swelling ­ less need for analgesics

Cooling with HILOTHERAPY ®

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Face lift, pre­operative Face lift, post­operative (24hrs)

Cooling with HILOTHERAPY ®

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2,67

3,73

2,67

3,67

3,93

4,13

1,40

1,20

1,40

1,20

1,40

1,27

1,00 1,50 2,00 2,50 3,00 3,50 4,00 4,50 5,00

Temperature tolerance

Comfort

Pain

Facial Swelling

Nasal Swelling

Overall assessment

HILOTHERAPY (n=40)

conventional treatment (n=29)

Patients‘ Evaluation Interview has been carried out at the „Klinik und Poliklinik für Hals­Nasen­Ohrenheilkunde, Klinikum München Großhadern“ Subject: Hilotherapy´s influence on woundhealing after Rhinoplasty

5 = very poor

1 = very good

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Medical Evaluation Interview has been carried out at the „Klinik und Poliklinik für Hals­Nasen­Ohrenheilkunde, Klinikum München Großhadern“ Subject: Hilotherapy´s influence on woundhealing after Rhinoplasty

• Post­operative targeted cooling of the operation site

• Simple application leading to high acceptance

• Notable reduction of post­operative swelling and bleeding peri/infraorbital with Hilotherm®

• Improved wound healing

• High level of acceptance with the patients (questionnaires).

• Reduced need for painkillers

• Shorter period of being signed off work

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Prof. Dr. Dr. Bull, Krefeld Recommendation

• The Hilotherm System has been used at the clinic for plastic­reconstructive, aesthetic facial surgery in Krefeld in numerous different head and neck operations.

• Acceptance by the patients is good.

• We are extremely pleased with the medical results.

• We can recommend Hilotherapy for the reduction of pain, as well as for the prophylaxis and treatment of swelling and hematoma.

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Prerequisites for successful HILOTHERAPY ®

„With the treatment of acute injuries whereby the reduction of swelling, pain and infection are a priority, the combined application of cold and compression is the choice treatment” [Meeusen R.]

1. Standard therapy for sports injuries

• The treatment for sports injuries consists of rest, localized cold applications, compression and elevation of the injured extremity (RICE: Rest, ICE, Compression, Elevation).

2. Compression!

• After the laying­on of the compression on the lower thigh, the increased pressure shows the decrease of circulation of approximately 50% at 40mm/Hg (40:Nielsen H.V.). The external rise in pressure hinders (by compression of the underlying tissue) the flow of fluid into the tissue and therefore counteracts the formation of edema (2:Knight K.L.).

3. Compression!

• Tests using compression bandages on ankle joints have shown that the LYMPHATIC FLOW is significantly increased with simultaneous cooling and compression ­ this leads to a quicker reduction of swelling (38:Meeusen R. et al.).

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Prerequisites for successful HILOTHERAPY ®

4. Elevation!

• In the same way, an elevation (by causing a drop in hydrostatic pressure) causes reduced formation of edema. With elevation, the reduction in circulation is more distinctive than with compression and, due to the setting in of the auto­regulation, occurs only with a reduction of pressure in the local arteries of more than 30 mm/Hg (41:Nielsen H.V.)

5. Avoid the application of ice!

• Ice or cold packs should never be directly laid on the skin. It is safer to use indirect application by means of a bandage or hand towel. In order to avoid freezing and nerve paralysis, long­term direct application of ice bags or industrial cold applications must be avoided particularly in the area of immediately subcutaneous nerve tracts.

• Special cooling systems are better suited whereby there is no danger of freezing or nerve damage.

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Which Temperatures?

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Which Temperatures?

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References

Clinic/Practice Medical field

• Bad Homburg, Kreisklinikum Hochtaunus • Berlin, Universitätsklinik Charité CBF • Berlin, Schlossparkklinik • Dessau, Städtisches Klinikum • Düsseldorf, Universitätsklinik • Gießen, Universitätsklinik • Halle­Wittenberg, Universitätsklinik • Heidelberg, Universitätsklinik • Kiel, Universitätsklinik • Krefeld, St. Josefshospital • Münster, Universitätsklinik • Chemnitz, Klinikum • Münster, Fachklinik Hornheide • Osnabrück, Klinikum • Regensburg, Universitätsklinik • Schwäbisch­Gmünd, Staufer­Klinik • Würzburg, Universitätsklinik • Tübingen, Universitätsklinik • Ulm, Bundeswehrkrankenhaus • Bietigheim, Krankenhaus • Essen, Universitätsklinik • Salzburger Landeskliniken, Paracelsusklinik • Privatklinik Bethanien Zürich

Oral and Maxillofacial surgery

Clinic/Practice Medical field

• Baden­Baden, Dres. Kotrikova und Semiotis • Bad Homburg, Dr. Dr. Kater • Böblingen, Dres. Beck, Birkenhagen, Peters • Coburg, Dres. Feller und Otte • Düsseldorf, Dr. Dr. Gutsche • Heidenheim, Dres. Fröschl & Steckeler • Ludwigsburg, Dr. Dr. Schmetzer • München, Dr. Dr. Haase • Mutlangen, Dr. Dr. Keweloh • Nürtingen, Dr. Dr. Henßler • Osnabrück, Dr. Dr. Bartnik • Ratingen, Dr. Dr. Loxtermann • Stuttgart, Dres. Lübbe, Meschenmoser, Deniz • Troisdorf, Dr. Dr. Kinder • Waldshut­Tiengen, Dr. Dr. Dorow • Würzburg, PD Dr. Dr. Bill • Dortmund, Praxisklinik Nilius • Eckental, MKG Zentrum, Dr. Wolski • Bad Nauheim, Zahnarztpraxis Dr. Merk • München, Dr. Dr. Seeliger • München, Paracelsusklinik • Köln, Clinic Rheinauhafen, Zahnmedizin • Düsseldorf, Kö 68

Oral and Maxillofacial surgery

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References

• Darmstadt, Rosenparkklinik • Görlitz, Städtisches Klinikum • Münster, Evangelisches Krankenhaus • Wesseling, Dreifaltigkeitskrankenhaus • Zürich, Privatklinik Bethanien • Berlin, Dr. Kauder • Hamburg, Dr. Meyer Praxisklinik Brahmsallee • Leipzig, Dres. Kaisers und Horak • Ludwigsburg, Dr. Grübmeyer • Ludwigsburg, Dr. Schmetzer • Nürnberg, Dr. Kunze • Mannheim, Dr. Solz • Nürnberg, Norisklinik Dr. Sebastian • Düsseldorf, Dr. Neidel • Seligenstadt, EMMA Klinik • Bergisch Gladbach, Parkklinik Schloss Bensberg

• Lindau, Zentrum für Chirurgie Bodensee • Kassel, Rotes Kreuz Krankenhaus • Düsseldorf, KÖ­Klinik

• Dr. Öhler, Sun Welly Klinik, Obermieming, Österreich

• Dr. Almasbegy, Innsbruck, Österreich

Plastic / Aesthetic surgery

Clinic/Practice Medical field

• Gera, SRH Waldklinikum • München, Universitätsklinikum Rechts der Isar • Essen, Laser Medizin Zentrum (LMZ) • München, Dr. Storck • Recklinghausen, Knappschaftskrankenhaus • Heilbronn, Hautklinik der SLK­Kliniken • Hildesheim, Hautzentrum • Hamburg, Dermatologikum

Dermatology

• Berlin, Parkklinik Weißensee • Borna, Helios Klinikum • Darmstadt, Rosenparkklinik • Gera, SRH Wald­Klinikum • Heidelberg, Universitätsklinik • Leipzig, Universitätsklinik • Leipzig, Diakonissenkrankenhaus • München­Großhadern, Universitätsklinik • Recklinghausen, Prosperhospital • Ulm, Bundeswehrkrankenhaus • Ulm, Universitätsklinikum • Stuttgart, Katharinenhospital

• Salzburger Landeskliniken, St. Johanns­Spital

Ear, Nose and Throat medicine

Clinic/Practice Medical field

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References

• Frankfurt am Main, Berufsgenossenschaftliche Unfallklinik

• Ulm, Rehabilitationsklinikum • Barcelona, Spanien, Dr. Jordi Ardevol, Medical Director F.C. Barcelona

• Gelsenkirchen, Gregor Zieleznik • Stuttgart, Dr. Degwert • Donaustauf, Eden­Reha, Klaus Eder • Bonn, Alexander Frese • Offenbach, Rehazentrum SPOREG • Herrenberg, Medizinische Fitness, Manfred Schumann

• Fellbach, VPT­Akademie • Balingen, Physiotherapie Roller • München, Physio & Docs • Bad Griesbach, Medical Center Golfhotel Maximilian

• Krefeld, St. Josefshospital • Königsbrunn, Revital Therapiezentrum • Fellbach, Rehazentrum Dr. Käsemann

Physical Therapy, Physiotherapy, Sports medicine

Clinic/Practice Medical field

• Freiburg, Universitätsklinik • Traunstein, Klinikum • Krefeld, St. Josefshospital • Hamburg, Park­Klinik Blankenese • Starnberg, Zentrum für Handchirurgie, Dr. Strassmair

• Fellbach, Dr. B. Käsemann

Orthopaedics, Traumatology

Clinic/Practice Medical field

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Contra­indications for Hypothermia (abstract)

With particular illnesses the use of localised cold applications can aggravate the disease pattern and therefore should not be used (1­4):

• Raynaud‘s syndrome and other vasospastic illnesses • Allergies to the cold (cold urticaria, cold hemoglobinuria, cold purpura, cold erythema) • Localised circulatory disturbances (arterial occlusive disease, chronic venal insufficiency) • Heart and circulatory problems (in the cases of coronary heart disease, cardiac insufficiency or

high blood pressure, a cold therapy could possibly lead to an acute worsening of the condition.) • Neurological losses such as paresis, paraesthesia and polyneuropathy • Important: No cold applications on open wounds!

References: 1. Borgia J.F.; Horvath S.M.: Reflex cardiac effects of local cutaneous cold exposure in dogs. Am.J.Physiol. 1980; 239:H 114­120. 2. Greene M.A.; Boltax A.J.; Lustig G, Rogow E.: Circulatory dynamics during the cold pressor test. Am.J.Cardiol 1965; 16:54­60. 3. Knight K.L.: Cryotherapy: Theory, Technique and Physiology. 1 ed. Chattanooga: Chattanooga Corporation, 1985. 4. Schröder D.; Anderson M.: Kryo­und Thermotherapie: Grundlagen und praktische Anwendung. Stuttgart: Gustav Fischer Verlag, 1995.

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Temperature development (abstract)

• The temperature fall when using cold applications is dependent upon

­ the difference in temperature between the skin and environment (cooling medium)

­ the size of the area to be treated ­ the period of the cold application ­ the amount of warmth which is either absorbed or

conducted by the cooling medium ­ the extent of the re­warming through circulation and

warmth conduction from the surrounding tissue (2:Knight K.L.) and

­ the percentage of fatty tissue; i.e. the lesser the percentage the greater the intramuscular temperature fall (48:Johnson D.J. et al.)

Air temperature

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Temperature development (abstract)

• There is a noticeable, quick fall in temperature of the skin and the subcutaneous tissue whilst the temperature of the muscle falls slowly until reaching a plateau (5:Thorsson O. et al.; 49:Hartviksen K.; 52:Oosterveld F.G. et al.)

• After stopping the cooling, the following occurs ­ initially the skin temperature rises quickly, ­ the inter­muscular as well as the intra­articular

temperature continues to fall, ­ this before the warming process starts again

(49:Hartviksen K.; 52:Oosterveld F.G. et al.)

Æ The described flow of warmth is the cause of the re­ warming time (which can last for many hours) until the inter­muscular and/or intra­articular starting temperature is reached (48:Johnson D.J. et al.; 50:Kern H. et al.)

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Origins of pain/pain reduction through HILOTHERAPY ®

Reduction of pain mediators

Less release of pain producing substances occurring naturally in the body (mediator, to which H­ und K­Ions, histamine, serotonin, prostaglandin and bradykinin belong), due to the reduction of tissue damage related to hypoxia. Through sensitization of the nociceptors, being responsible for sense of pain, prostaglandin causes an increased release of substance P (neurotransmitter). This in turn effects the degranulation of mast cells, which are related to the release of histamine and serotonin. As well as bradykinin histamine provokes either vasodilatation and increased capillary permeability. The associated rise in tissue pressure irritates the highly sensitive nociceptors.

hypoxia

edema

Nociceptors

Neurotransmitter Substance P

CGRP

mast cell delay

acidosis

pain­ mediators

prostaglandin bradykinin

vasodilatation Increase in capillary

permeability

histamine serotonin

hypothermia

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Minimum release of edema building substances

The synovial tissue of human joints is high in neurotransmitters like CGRP and substance P, which are released through nerve endings in case of inflammation. In conjunction with prostaglandin, histamine and substance P CGRP raises the local building of edema many times over. It raises the increase of capillary permeability, caused by the above mentioned substances. This reaction can even be observed on the uninjured opposite side.

Origins of pain/pain reduction through HILOTHERAPY ®

hypoxia

edema

Nociceptors

neurotransmitter Substance P

CGRP

mast cell decay

acidosis

pain­ mediators

prostaglandin bradykinin

vasodilatation Increase in capillary­

permeability

histamine serotonin

hypothermia

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Origins of pain/pain reduction through HILOTHERAPY ®

Lowering of neural transmit rapidity

In inflamed knee­joints an increased recruitment and sensitization of mechanoreceptive nociceptive nerve fibres can be observed. In healthy knee­joints these nerve fibres only show little neural impulses, even after stimulation through forced joint motions. By contrast, in inflamed knee­joints a strong impulse is already caused by a low motion stimulus.

The heightening of the pain threshold

During a cold application the neural transmit rapidity is reduced and the refractory period is extended so that the afferent impulse declines (1). Thereby the response is reduced (6) and the pain threshold is raised (2).

hypoxia

edema

Nociceptors

neurotransmitter Substance P

CGRP

mast cell decay

acidosis

pain­ mediators

prostaglandin bradykinin

vasodilatation Increase in capillary­

permeability

histamine serotonin

hypothermia

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Origins of pain/pain reduction through HILOTHERAPY ®

The Avoidance of Muscle spasticity The increase of pain with each motion or muscle relaxation prompts the patient to take a position as inflexible as possible and thus supports painful muscle spasticity. According to Knight this cycle can be discontinued through the above described neurological effects of cold therapy.

reduced reflexes

extent of movement

pain reduction

rehabilitation

hypothermia

reduced muscle spasticity

muscle relaxation mobilisation

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Literature (1) Schaubel H.J.: The local use of ice after orthopaedic procedures. Am.J.Surg. 72:711­714, 1946 (2) Knight K.L.: Cryotherapie: Theorie, Technique and Physiologie. 1. Auflage, Chattanooga Corp., 1985 (3) Knight K.L.; Londeree B.R.: Comparison of blood flow in the ankle of uninjured subjects during therapeutic applications of heat, cold and exercise.

Med.Sci.Sports Exerc. 12(1):76­80, 1980 (4) Liman W.; Fricke R.; Taghawinejad M.; Bernstein H.: Arterielle Durchblutung unter Kryotherapie bei chronischer Polyarthritis.

Z.Phys.Med.Baln.Med.Klim. 11:196­201, 1982 (5) Thorsson O.; Lilja B.; Ahlgren L.; Hemdal B.; Westlin N.: The effect of local cold application on intramuscular blood flow at rest and after running.

Med.Sci.Sports.Exerc. 17(6):710­713, 1985 (6) Löffler G.; Petrides P.E.; Weiss L.; Harper H.A.: Physiologische Chemie. 2. Auflage, Berlin: Springer, 1979:171 (7) Harris E.D.Jr.; McCroskery A.: The influence of temperature and fibril stability on degradation of cartilage collagen by rheumatoid synovial collganese.

New.Eng.J.Med. 290:1­6, 1974 (8) McMaster W.C.; Liddle S.: Cryotherapy influence on posttraumatic limb edema. Clin.Orthop. 150:283­287, 1980 (9) Wright J.G.; Araki C.T.: Belkin M.; Hobson R.W.: Postischemic hypothermia diminishes skeletal muscle reperfusion edema. J.Surg.Res. 47:389­396,

1989 (10) Svanes K.: The influence of deep hypothermia on the formation of fluid exsudate in acute inflammation in mice. Acta.Anaesthesiol Scand. 8:157­166,

1964 (11) Svanes K.: The influence of deep hypothermia on the formation of cellular exsudate in acute inflammation in mice. Acta.Anaesthesiol Scand. 8:143­

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44:754­763, 1988 (15) Matsen F.A.III; Questad K.; Matsen A.L.: The effect of local cooling on post­fracture swelling. Clin.Orthop. 109:201­206, 1975 (16) Abramson D.I.; Chu L.S.W.; Tuck S.jr.; Lee S.W.; Richardson G.; Levin M.: Effect of tissue temperature and blood flow on motor nerve conduction

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