Chapter 14 Application Procedures Post Immediate Care Cryotherapy

Chapter 14. Application Procedures: Post– Immediate Care Cryotherapy © 2008 LWW

Transition and Subacute Care Cryotherapy • Begin once secondary injury stops • Usually within 24 hr • Used for very different reasons than during immediate care – Decrease pain and inhibition – Facilitate pain-free therapeutic exercise © 2008 LWW

Transition and Subacute Care Cryotherapy (cont. ) • Application types and times differ • The key: exercise, not the cold © 2008 LWW

Local Numbing with Cryotherapy • Ice water immersion • Ice massage • Ice bag (occasionally) © 2008 LWW

Ice Water Immersion • Ice bath immersion – Not ice water submersion • Key points – Large enough container • Plastic or rubber best – Fill with ice, then water. • Goal is 32– 34°F (0– 1°C). – Warmer water does not numb as effectively. © 2008 LWW

Ice Water Immersion (cont. ) • Initial cooling usually quite painful; help patient adapt by – Giving patient a choice before beginning treatment. – Assuring patient that subsequent bouts and sessions will be much less painful. – Using a toe cap to minimize pain. – Talking to patient during initial immersion to take her mind off the cold. – Making sure patient goes through multiple immersion bouts during first session. © 2008 LWW

Ice Massage • Slowly stroke muscle with ice pop. • Discontinue when numb. • Adding a plate weight will increase numbness. © 2008 LWW

Ice Massage (cont. ) • Prepare ice pops by – Freezing water in 6– 8 oz. paper cups – Add tongue depressor to some for handle. © 2008 LWW

Transition and Subacute Care Cryotherapy: Techniques • • Cryokinetics Cryostretch Contrast bath Connective tissue stretch © 2008 LWW

Cryokinetics Combination of cold application and active exercise © 2008 LWW

Why Cryokinetics? • Cold decreases pain, which – Facilitates active exercise • Exercise – Reduces swelling (dramatically) through muscular milking action – Promotes healing and return to function – Reduces inhibition © 2008 LWW

Cryokinetics: Disadvantages • Pain during initial session • Cold can be messy. © 2008 LWW

Cryokinetics: Indications • Sprains—dynamite treatment – Ankle (especially) – Fingers © 2008 LWW

Cryokinetics: Contraindications • Any exercise or activity that causes pain • Use of ice on a patient who is hypersensitive to cold © 2008 LWW

Cryokinetics: Precautions • Use pain as a guideline. – Warn patient not to gut out pain. • Don’t allow patient to limp. • May be an increase in pain 4– 8 hr after treatment © 2008 LWW

Cryokinetics: Overview • Typically consists of five bouts of exercise interspersed with cold application for numbing © 2008 LWW

Cryokinetics Preapplication Tasks for Proper Modality • Reevaluate injury. • Review previous treatment, if any. • Confirm that objectives of therapy are compatible with cryotherapy, • Check that cryokinetics is not contraindicated. © 2008 LWW

Cryokinetics Preapplication Tasks for Psychological Preparation • Explain sensations • Cold very painful during first immersion. – Adapt thereafter – Benefits of treatment outweigh temporary pain © 2008 LWW

Cryokinetics Preapplication Tasks for Physical Preparation • Remove clothing as necessary. • Position patient. © 2008 LWW

Cryokinetics Preapplication Tasks for Equipment Preparation • Container and ice or ice pop • Toe cap is helpful. • Towels to sop up water © 2008 LWW

Cryokinetics Application to Numb Body Part • Apply ice. – Immersion is best. • 1°C water – Use ice massage if cannot immerse. © 2008 LWW

Cryokinetics Application to Numb Body Part (cont. ) • Apply until body part is numb. – Usually 10– 20 min – Goal is numbness, not time – Stop application after 20 min whether or not patient feels numb • Some people (10– 20%) cannot tell when they are numb. © 2008 LWW

Cryokinetics Application to Numb Body Part (cont. ) • Toe cap or sock keeps toes warm. © 2008 LWW

Cryokinetics Application for Exercise • As long as numb (~3 min) • Reapply ice until numb again (3– 5 min) • Exercise–ice–exercise–ice • Five exercise bouts per treatment • Exercise, not ice, causes rehabilitation. © 2008 LWW

Principles of Cryokinetics Exercise • All exercise should be active. • Performed by the patient • Exercise must be graded • Begin with range of motion exercises. • Progress through increasing levels of difficulty. • Full sport activity is final level. • Example for ankle injury follows. © 2008 LWW

Principles of Cryokinetics Exercise: Example • Let pain be your guide. • Never use an exercise that causes pain. • If painful, return to former activity level. • Go through complete ROM (or as much as is possible). • Perform all exercise without ankle taping, as long as ice is being used. © 2008 LWW

Principles of Cryokinetics Exercise: Example (cont. ) • Non-weight-bearing ROM – – – Plantar flexion Dorsiflexion Inversion Eversion Circumduction © 2008 LWW

Principles of Cryokinetics Exercise: Example (cont. ) • Weight-bearing ROM – Stand up. – Shift weight from foot to foot. – Gradually increase weight on injured limb. © 2008 LWW

Principles of Cryokinetics Exercise: Example (cont. ) • Walk 1 • • • Small steps Heel to toe Slow and deliberate • • No limp No pain Progress to. . . © 2008 LWW

Principles of Cryokinetics Exercise: Example (cont. ) • Walk 2 • • • Medium steps Slow and deliberate Then a little faster • • No limp No pain Progress to. . . © 2008 LWW

Principles of Cryokinetics Exercise: Example (cont. ) • Walk 3 Large steps Straight ahead Around things or in lazy S • Injured leg inside and outside curve Progress to. . . • • • © 2008 LWW

Principles of Cryokinetics Exercise: Example (cont. ) • Stretch heel cords, if necessary © 2008 LWW

Principles of Cryokinetics Exercise: Example (cont. ) • Strengthen muscles Dorsiflexion, eversion, inversion • With Elgin ankle exerciser Progress to. . . • © 2008 LWW

Principles of Cryokinetics Exercise: Example (cont. ) • Jog Straight ahead Lazy S Sharp Z Work into running Progress to. . . • • © 2008 LWW

Principles of Cryokinetics Exercise: Example (cont. ) • Four-square exercises © 2008 LWW

Principles of Cryokinetics Exercise: Example (cont. ) • Perform individual drills • With ankle taped • ½ speed • ¾ speed • Full speed © 2008 LWW

Principles of Cryokinetics Exercise: Example (cont. ) • Perform team drills • With ankle taped • ½ speed ¾ speed • Full speed • © 2008 LWW

Cryokinetics: Summary • Exercise – – – After numbing (12– 20 min) For as long as numb (~3 min) Reapply ice until numb again (3– 5 min) Exercise–ice–exercise–ice Five exercise bouts per treatment Exercise, not ice, causes rehabilitation. © 2008 LWW

Cryokinetics: Summary (cont. ) • When to begin – – Within 30 min if first-degree sprain Next day if second-degree sprain Never if third-degree sprain With cryostretch if strain © 2008 LWW

Cryokinetics: Application Parameters • Dosage – Exercise as vigorously as possible but within the limits of pain. – Most new clinicians will not encourage their patients to progress as rapidly as possible. © 2008 LWW

Cryokinetics: Application Parameters (cont. ) • Length of application – Five exercise bouts per treatment session • Frequency of application – Two or three times per day • Duration of therapy – Until patient returns to full, unhindered activity © 2008 LWW

Cryokinetics Postapplication Tasks • Instructions to the patient – Leave with the same joint support you came with. – If after a few hours the support is not needed, discontinue using it. – Be active, as long as pain free. – May feel pain in 4– 8 hr; if so, apply an ice pack for 30 min. • Schedule the next treatment. • Record treatment, including unique patient responses. • Clean up area. © 2008 LWW

Cryokinetics: Maintenance • Replace slush container when it cracks. • Sew sides of toe caps if they rip. © 2008 LWW

Cryostretch for Muscle Injuries • Most (strains and contusions) result in muscle spasm or tightness. • Many mild muscle pulls are actually muscles in spasm rather than torn muscle fiber. • Reduce spasm with cryostretch. © 2008 LWW

Rehabilitation Goals • • Promote healing, if tissues torn. Control pain. Reduce spasm. Control neural inhibition. © 2008 LWW

Rehabilitation Goals (cont. ) • Reset central control through aggressive, progressive reorientation to full function. • Develop muscle strength. • Promote other phases of rehabilitation as explained earlier. © 2008 LWW

Begin with Cryostretch Then transition into cryokinetics (for firstand second-degree injuries) © 2008 LWW

Cryostretch: Foundation • Combination of the muscle spasm reduction techniques • Cold application • Static stretching • Hold–relax technique of PNF © 2008 LWW

Cryostretch: Foundation (cont. ) Ice Static stretch Isometric contraction © 2008 LWW

Cryostretch: Effects • Ice decreases pain and muscle spasm. • Static stretching overcomes stretch reflex, thus decreasing muscle spasm. • Relaxation after maximal muscular contraction is greater than before contraction. © 2008 LWW

Cryostretch: Advantages l l Combined procedure more effective than the sum of the three individual components Ice inexpensive; exercise free © 2008 LWW

Cryostretch: Disadvantages l Ice is painful to some people. l l But massage not as painful as ice immersion. Melting ice can be messy. © 2008 LWW

Cryostretch: Indications l l l Any muscle with residual, low-grade muscle spasm Any first-degree muscle strain A muscle that is stiff from prolonged disuse (immobilization) l Do not confuse this with decreased ROM owing to connective tissue contractures. © 2008 LWW

Cryostretch: Contraindications l l Any exercise or activity that causes pain Use of ice on a person who is hypersensitive to cold © 2008 LWW

Cryostretch: Precautions • Don’t allow patient to consciously or willfully overcome or gut out the pain. • There may be an increase in pain 4– 8 hr after treatment. • Isometric contractions must begin and end gradually. – Sudden starts or stops may tear muscle fibers. © 2008 LWW

Cryostretch: Application Parameters • Three sets – Numb with ice then activity • Activity consists of two 65 sec bouts of exercise with 20 sec rest between bouts • 65 sec bout – Stretch muscle to limits and hold 20 sec – Three static stretches, interspersed with maximal isometric contraction (hold–relax) © 2008 LWW

Cryostretch: Application Parameters (cont. ) – Example exercise bout • • 20 sec static stretch 5 sec isometric contraction 10 sec static stretch © 2008 LWW

Cryostretch: Application Parameters (cont. ) Numb/renumb Static stretch Isometric contraction First bout Second bout © 2008 LWW First set Second set Third set

Cryostretch: Application Parameters (cont. ) • • Numb muscle (20 min max) 65 sec stretch–contraction 20 sec rest Repeat 65 sec stretch–contraction Renumb Two more stretching bouts (20 sec rest) © 2008 LWW

Cryostretch: Application Parameters (cont. ) Numb (20 min max), with ice massage © 2008 LWW

Cryostretch: Application Parameters (cont. ) • Neuromuscular training – Part of first day, first bout only – Help patient feel the use of the affected muscle by actively contacting it through ROM. – Offer minimal resistance. – Repeat two to three times. © 2008 LWW

Cryostretch: First Bout, First Stretch • 20 sec static stretch – Stretch muscle to limit; hold 20 sec © 2008 LWW

Cryostretch: First Bout, First Contraction • 5 sec isometric contraction – Instruct patient to begin and end slowly. – No quick stops and starts – Instruct patient to attempt the same movement as before, but this time you will hold body part so it doesn’t move. © 2008 LWW

Cryostretch: First Bout, Second Stretch • 10 sec static stretch – Take up slack from first contraction. – Move to limits of tightness/pain. – Hold 10 sec. © 2008 LWW

Cryostretch: First Bout, Second Contraction • 5 sec isometric contraction – Instruct patient to begin and end slowly, as before. © 2008 LWW

Cryostretch: First Bout, Third Stretch • 10 sec static stretch – Take up slack from second contraction. – Move to limits of tightness/pain. – Hold 10 sec. © 2008 LWW

Cryostretch: First Bout, Third Contraction • 5 sec isometric contraction – Instruct patient to begin and end slowly, as before. © 2008 LWW

Cryostretch: Between First and Second Bout • Rest 20 sec © 2008 LWW

Cryostretch: Second Bout • Repeat first bout – 65 sec © 2008 LWW

Cryostretch: Second and Third Sets • Renumb (5 min max) • Repeat set © 2008 LWW

Cryostretch: Overall Numb/renumb Static stretch Isometric contraction © 2008 LWW

Cryostretch: Miscellaneous Tips • Use shoulder if patient is too big. © 2008 LWW

Cryostretch: Miscellaneous Tips (cont. ) • Stretch muscle until pain or tightness is felt, then back off until pain disappears. © 2008 LWW

Cryokinetics: Application Parameters Revisited • Dosage – Exercise as vigorously as possible but within the limits of pain. – Most new clinicians will not encourage their patients to progress as rapidly as possible. © 2008 LWW

Cryokinetics: Application Parameters Revisited (cont. ) • Length of application – Five exercise bouts per treatment session • Frequency of application – Two to three times per day • Duration of therapy – Until patient returns to full, unhindered activity © 2008 LWW

Cryokinetics: Postapplication Tasks Revisited • Instructions to the patient – Leave with the same joint support you came with – If after a few hours the support is not needed, discontinue using it. – Be active, as long as pain free. – May feel pain in 4– 8 hr; if so, apply an ice pack for 30 min. © 2008 LWW

Cryokinetics: Postapplication Tasks Revisited (cont. ) • Schedule the next treatment. • Record treatment, including unique patient responses. • Clean up area. © 2008 LWW

Cryokinetics: Maintenance Revisited • Replace slush container when it cracks. • Sew sides of toe caps if they rip. © 2008 LWW

Combined Cryostretch and Cryokinetics • Begin once spasm begins to abate. – Often within 2– 3 days • Replace stretching with active (isotonic) exercise. © 2008 LWW

Combined Cryostretch and Cryokinetics (cont. ) • Begin and end with stretch. • Begin cryokinetics exercises with manually resisted muscle contractions (6– 10) through a full ROM. © 2008 LWW

Combined Cryostretch and Cryokinetics (cont. ) • Once strength begins to return (2–days), switch to some type of isotonic weight lifting • Use DAPRE technique © 2008 LWW

Combined Cryostretch and Cryokinetics (cont. ) Progress through all phases of rehabilitation using progressive functional activities. © 2008 LWW

The Last Word on Muscle Injury • Muscle injury is often the result of failure to – Properly strengthen muscle – Resume full activity in a progressive, gradual way • Don’t allow the patient to return to explosive activity prematurely. © 2008 LWW

Connective Tissue Stretch • Technique to break tissue contractures • Used to increase joint flexibility after prolonged immobilization © 2008 LWW

Connective Tissue Stretch: Foundation • Combination of – Heat application – Long-term passive stretch – Cold applications © 2008 LWW

Connective Tissue Stretch: Foundation (cont. ) • 45 min treatment © 2008 LWW

Connective Tissue Stretch: Effects • Heat causes collagen cross-bridges to relax. • Stretch lengthens the collagen. • Cold causes the collagen cross-bridges to reattach in a lengthened position. © 2008 LWW

Connective Tissue Stretch: Advantages • Heat applications minimize collagen tearing by inducing cross-bridge relaxation. • Cold applications cause the crossbridges to reform in a lengthened position, thus preserving the gains made during stretching. • Minimal equipment needed © 2008 LWW

Connective Tissue Stretch: Disadvantages • Boring treatment © 2008 LWW

Connective Tissue Stretch: Indications • Anytime connective tissue contractures prevent full ROM © 2008 LWW

Connective Tissue Stretch: Contraindications • Any exercise or activity that causes pain • Use of ice on a person who is hypersensitive to cold © 2008 LWW

Connective Tissue Stretch: Precautions • Avoid pain during stretching. – Usually occurs because resistance is too great © 2008 LWW

Connective Tissue Stretch: Alternatives – Diathermy – Mobilization © 2008 LWW

Connective Tissue Stretch: Application Parameters • Heat injured joint for 15– 30 min, depending on modality used. – Shortwave pulsed diathermy is preferred for heating large areas (15– 20 min). – Moist hot packs if diathermy unavailable (30 min). – Apply to both sides if it is a large joint. – Change hot packs after 15 min to compensate for their cooling. © 2008 LWW

Connective Tissue Stretch: Application Parameters (cont). • Stretch joint with low-level continuous passive force for 15 min. – Begin after 15 min of heating. – Use external force • Example: 3– 15 lb weight – No manual resistance – No specific way to apply resistance • Use your ingenuity. © 2008 LWW

Connective Tissue Stretch: Application Parameters (cont. ) • Discontinue heating and begin cooling after 15 min of stretching. • Maintain stretch – Collagen fibers that detached during heating will reattach during cooling if joint is held in lengthened position. © 2008 LWW

Connective Tissue Stretch: Application Parameters (cont. ) • Dosage – As much resistance as comfortable © 2008 LWW

Connective Tissue Stretch: Application Parameters (cont. ) • Length of application – 45 min per treatment session • Frequency of application – Two to three times per day • Duration of therapy – Until patient returns to full, unhindered activity. © 2008 LWW

Connective Tissue Stretch: Postapplication Tasks • Instructions to the patient – Be active, as long as pain free. – May feel pain in 4– 8 hr; if so, apply an ice pack for 30 min. © 2008 LWW

Connective Tissue Stretch: Postapplication Tasks (cont. ) • Schedule the next treatment. • Record treatment, including unique patient responses. • Clean up area. © 2008 LWW

Lymphedema Pumps • Pumps attached to boot or sleeve and force air or water into sleeve. • Pumps turn on and off so sleeve alternates inflating and deflating, providing intermittent compression. © 2008 LWW

Lymphedema Pumps: Foundation • Formerly called: – – Intermittent compression pumps Cold compression devices Pneumatic compression pumps Intermittent compression devices © 2008 LWW

Lymphedema Pumps: Foundation (cont. ) • Classified as: – – Pneumatic (air) Cryocompression (chilled water) Circumferential (all at once) Sequential (distal to proximal) © 2008 LWW

Lymphedema Pump: Effects • Changes in sleeve pressure forces lymphatic and venous drainage and thus reduces edema. – Permanent edema reduction requires free protein and cellular debris removal from tissue. – So capillary filtration pressure is normalized. • Lymphatic and venous systems contain one-way valves that allow contents to move proximally but block distal movement. © 2008 LWW

Lymphedema Pump: Advantages • Requires minimal clinician time © 2008 LWW

Lymphedema Pump: Disadvantages • Slow rate of boot/sleeve inflation • Tissue compression rate much faster with active exercise and massage. © 2008 LWW

Lymphedema Pump: Indications • • • Post-traumatic edema Postoperative edema Chronic edema Primary and secondary lymphedema Venous stasis ulcers Persistent swelling from venous insufficiency © 2008 LWW

Lymphedema Pump: Contraindications • In patients suffering from: – – – Compartment syndrome Peripheral vascular disease Arteriosclerosis Deep vein thrombosis Local superficial infection Edema secondary to congestive heart failure Ischemic vascular disease Gangrene Dermatitis Acute pulmonary edema Displaced fractures © 2008 LWW

Lymphedema Pump: Precautions • Avoid pain during treatment. © 2008 LWW

Lymphedema Pump: Alternatives • Active muscle activity • Massage © 2008 LWW

Lymphedema Pump: Preapplication Tasks • Same as cryokinetics preapplication tasks © 2008 LWW

Lymphedema Pump: Application Parameters • Apply sleeve or boot to extremity and tighten it so it’s snug but doesn’t apply pressure to the limb. • Attach the sleeve tube to the pump. • If using a water device, fill the water container with ice and water. • Select on–off times. • Turn on the device. © 2008 LWW

Lymphedema Pump: Application Parameters (cont. ) • Dosage – Inflation pressure • 40– 60 mm Hg for upper extremity • 60– 100 mm Hg for lower extremity, but no greater than the patient’s diastolic pressure – On–off time sequence • 45– 15 sec; 3: 1 duty cycle © 2008 LWW

Lymphedema Pump: Application Parameters (cont. ) • Length of application – 20 min • Frequency of application – Two to three times per day • Duration of therapy – Until edema is resolved © 2008 LWW

Lymphedema Pump: Postapplication Tasks • Instructions to patient – Be active, as long as pain free • Schedule the next treatment. • Record treatment, including unique patient responses. • Clean up area. © 2008 LWW

Lymphedema Pump: Maintenance • Periodically check hoses, valves, boots, and sleeves for leaks. © 2008 LWW