1. © 2008 LWW Chapter 14. Application Procedures: Post– Immediate Care Cryotherapy

2. © 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

3. © 2008 LWW Application types and times differ The key: exercise, not the cold Transition and Subacute Care Cryotherapy (cont.)

4. © 2008 LWW Local Numbing with Cryotherapy Ice water immersion Ice massage Ice bag (occasionally)

5. © 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.

6. © 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.

7. © 2008 LWW Ice Massage Slowly stroke muscle with ice pop. Discontinue when numb. Adding a plate weight will increase numbness.

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

9. © 2008 LWW Cryokinetics Cryostretch Contrast bath Connective tissue stretch Transition and Subacute Care Cryotherapy: Techniques

10. © 2008 LWW Cryokinetics Combination of cold application and active exercise

11. © 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

12. © 2008 LWW Cryokinetics: Disadvantages Pain during initial session Cold can be messy.

13. © 2008 LWW Cryokinetics: Indications Sprains—dynamite treatment –Ankle (especially) –Fingers

14. © 2008 LWW Cryokinetics: Contraindications Any exercise or activity that causes pain Use of ice on a patient who is hypersensitive to cold

15. © 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

16. © 2008 LWW Cryokinetics: Overview Typically consists of five bouts of exercise interspersed with cold application for numbing

17. © 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.

18. © 2008 LWW Cryokinetics Preapplication Tasks for Psychological Preparation Explain sensations Cold very painful during first immersion. –Adapt thereafter –Benefits of treatment outweigh temporary pain

19. © 2008 LWW Cryokinetics Preapplication Tasks for Physical Preparation Remove clothing as necessary. Position patient.

20. © 2008 LWW Cryokinetics Preapplication Tasks for Equipment Preparation Container and ice or ice pop Toe cap is helpful. Towels to sop up water

21. © 2008 LWW Cryokinetics Application to Numb Body Part Apply ice. –Immersion is best. 1°C water –Use ice massage if cannot immerse.

22. © 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.

23. © 2008 LWW Cryokinetics Application to Numb Body Part (cont.) Toe cap or sock keeps toes warm.

24. © 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.

25. © 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.

26. © 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.

27. © 2008 LWW Principles of Cryokinetics Exercise: Example (cont.) Non-weight-bearing ROM –Plantar flexion –Dorsiflexion –Inversion –Eversion –Circumduction

28. © 2008 LWW Weight-bearing ROM –Stand up. –Shift weight from foot to foot. –Gradually increase weight on injured limb. Principles of Cryokinetics Exercise: Example (cont.)

29. © 2008 LWW Principles of Cryokinetics Exercise: Example (cont.) Walk 1 Small steps Heel to toe Slow and deliberate No limp No pain Progress to...

30. © 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...

31. © 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...

32. © 2008 LWW Principles of Cryokinetics Exercise: Example (cont.) Stretch heel cords, if necessary

33. © 2008 LWW Principles of Cryokinetics Exercise: Example (cont.) Strengthen muscles Dorsiflexion, eversion, inversion With Elgin ankle exerciser Progress to...

34. © 2008 LWW Principles of Cryokinetics Exercise: Example (cont.) Jog Straight ahead Lazy S Sharp Z Work into running Progress to...

35. © 2008 LWW Principles of Cryokinetics Exercise: Example (cont.) Four-square exercises

36. © 2008 LWW Principles of Cryokinetics Exercise: Example (cont.) Perform individual drills With ankle taped ½ speed ¾ speed Full speed

37. © 2008 LWW Principles of Cryokinetics Exercise: Example (cont.) Perform team drills With ankle taped ½ speed ¾ speed Full speed

38. © 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.

39. © 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

40. © 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.

41. © 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

42. © 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.

43. © 2008 LWW Cryokinetics: Maintenance Replace slush container when it cracks. Sew sides of toe caps if they rip.

44. © 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.

45. © 2008 LWW Rehabilitation Goals Promote healing, if tissues torn. Control pain. Reduce spasm. Control neural inhibition.

46. © 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.

47. © 2008 LWW Begin with Cryostretch Then transition into cryokinetics (for first- and second-degree injuries)

48. © 2008 LWW Cryostretch: Foundation Cold application Static stretching Hold–relax technique of PNF Combination of the muscle spasm reduction techniques

49. © 2008 LWW Ice Static stretch Isometric contraction Cryostretch: Foundation (cont.)

50. © 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.

51. © 2008 LWW l Combined procedure more effective than the sum of the three individual components l Ice inexpensive; exercise free Cryostretch: Advantages

52. © 2008 LWW l Ice is painful to some people. l But massage not as painful as ice immersion. l Melting ice can be messy. Cryostretch: Disadvantages

53. © 2008 LWW l Any muscle with residual, low-grade muscle spasm l Any first-degree muscle strain l A muscle that is stiff from prolonged disuse (immobilization) l Do not confuse this with decreased ROM owing to connective tissue contractures. Cryostretch: Indications

54. © 2008 LWW l Any exercise or activity that causes pain l Use of ice on a person who is hypersensitive to cold Cryostretch: Contraindications

55. © 2008 LWW 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. Cryostretch: Precautions

56. © 2008 LWW 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) Cryostretch: Application Parameters

57. © 2008 LWW –Example exercise bout 20 sec static stretch 5 sec isometric contraction 10 sec static stretch 5 sec isometric contraction 10 sec static stretch 5 sec isometric contraction 10 sec static stretch Cryostretch: Application Parameters (cont.)

58. © 2008 LWW Numb/renumb Isometric contraction Static stretch Cryostretch: Application Parameters (cont.) First setSecond setThird set Second boutFirst bout

59. © 2008 LWW 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) Renumb Two more stretching bouts (20 sec rest) Cryostretch: Application Parameters (cont.)

60. © 2008 LWW Numb (20 min max), with ice massage Cryostretch: Application Parameters (cont.)

61. © 2008 LWW 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. Cryostretch: Application Parameters (cont.)

62. © 2008 LWW Cryostretch: First Bout, First Stretch 20 sec static stretch –Stretch muscle to limit; hold 20 sec

63. © 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.

64. © 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.

65. © 2008 LWW Cryostretch: First Bout, Second Contraction 5 sec isometric contraction –Instruct patient to begin and end slowly, as before.

66. © 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.

67. © 2008 LWW Cryostretch: First Bout, Third Contraction 5 sec isometric contraction –Instruct patient to begin and end slowly, as before.

68. © 2008 LWW Cryostretch: Between First and Second Bout Rest 20 sec

69. © 2008 LWW Repeat first bout –65 sec Cryostretch: Second Bout

70. © 2008 LWW Cryostretch: Second and Third Sets Renumb (5 min max) Repeat set

71. © 2008 LWW Numb/renumb Isometric contraction Static stretch Cryostretch: Overall

72. © 2008 LWW Use shoulder if patient is too big. Cryostretch: Miscellaneous Tips

73. © 2008 LWW Cryostretch: Miscellaneous Tips (cont.) Stretch muscle until pain or tightness is felt, then back off until pain disappears.

74. © 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.

75. © 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

76. © 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.

77. © 2008 LWW Cryokinetics: Postapplication Tasks Revisited (cont.) Schedule the next treatment. Record treatment, including unique patient responses. Clean up area.

78. © 2008 LWW Cryokinetics: Maintenance Revisited Replace slush container when it cracks. Sew sides of toe caps if they rip.

79. © 2008 LWW Combined Cryostretch and Cryokinetics Begin once spasm begins to abate. –Often within 2–3 days Replace stretching with active (isotonic) exercise.

80. © 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.

81. © 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

82. © 2008 LWW Combined Cryostretch and Cryokinetics (cont.) Progress through all phases of rehabilitation using progressive functional activities.

83. © 2008 LWW 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. The Last Word on Muscle Injury

84. © 2008 LWW Connective Tissue Stretch Technique to break tissue contractures Used to increase joint flexibility after prolonged immobilization

85. © 2008 LWW Connective Tissue Stretch: Foundation Combination of –Heat application –Long-term passive stretch –Cold applications

86. © 2008 LWW Connective Tissue Stretch: Foundation (cont.) 45 min treatment

87. © 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.

88. © 2008 LWW Connective Tissue Stretch: Advantages Heat applications minimize collagen tearing by inducing cross-bridge relaxation. Cold applications cause the cross- bridges to reform in a lengthened position, thus preserving the gains made during stretching. Minimal equipment needed

89. © 2008 LWW Connective Tissue Stretch: Disadvantages Boring treatment

90. © 2008 LWW Connective Tissue Stretch: Indications Anytime connective tissue contractures prevent full ROM

91. © 2008 LWW Connective Tissue Stretch: Contraindications Any exercise or activity that causes pain Use of ice on a person who is hypersensitive to cold

92. © 2008 LWW Connective Tissue Stretch: Precautions Avoid pain during stretching. –Usually occurs because resistance is too great

93. © 2008 LWW Connective Tissue Stretch: Alternatives –Diathermy –Mobilization

94. © 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.

95. © 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.

96. © 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.

97. © 2008 LWW Connective Tissue Stretch: Application Parameters (cont.) Dosage –As much resistance as comfortable

98. © 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.

99. © 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.

100. © 2008 LWW Connective Tissue Stretch: Postapplication Tasks (cont.) Schedule the next treatment. Record treatment, including unique patient responses. Clean up area.

101. © 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.

102. © 2008 LWW Lymphedema Pumps: Foundation Formerly called: –Intermittent compression pumps –Cold compression devices –Pneumatic compression pumps –Intermittent compression devices

103. © 2008 LWW Lymphedema Pumps: Foundation (cont.) Classified as: –Pneumatic (air) –Cryocompression (chilled water) –Circumferential (all at once) –Sequential (distal to proximal)

104. © 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.

105. © 2008 LWW Lymphedema Pump: Advantages Requires minimal clinician time

106. © 2008 LWW Lymphedema Pump: Disadvantages Slow rate of boot/sleeve inflation Tissue compression rate much faster with active exercise and massage.

107. © 2008 LWW Lymphedema Pump: Indications Post-traumatic edema Postoperative edema Chronic edema Primary and secondary lymphedema Venous stasis ulcers Persistent swelling from venous insufficiency

108. © 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

109. © 2008 LWW Lymphedema Pump: Precautions Avoid pain during treatment.

110. © 2008 LWW Lymphedema Pump: Alternatives Active muscle activity Massage

111. © 2008 LWW Lymphedema Pump: Preapplication Tasks Same as cryokinetics preapplication tasks

112. © 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.

113. © 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

114. © 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

115. © 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.

116. © 2008 LWW Lymphedema Pump: Maintenance Periodically check hoses, valves, boots, and sleeves for leaks.