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

Chapter 14. Application Procedures: Post–Immediate Care Cryotherapy

Transition and Subacute Care CryotherapyTransition 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

• Application types and times differ• The key: exercise, not the cold

Transition and Subacute Care Cryotherapy (cont.)Transition and Subacute Care Cryotherapy (cont.)

Local Numbing with CryotherapyLocal Numbing with Cryotherapy

• Ice water immersion• Ice massage• Ice bag (occasionally)

Ice Water ImmersionIce 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.

Ice Water Immersion (cont.)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.

Ice MassageIce Massage

• Slowly stroke muscle with ice pop.

• Discontinue when numb.

• Adding a plate weight will increase numbness.

Ice Massage (cont.)Ice Massage (cont.)

• Prepare ice pops by– Freezing water in

6–8 oz. paper cups

– Add tongue depressor to some for handle.

• Cryokinetics• Cryostretch• Contrast bath• Connective tissue stretch

Transition and Subacute Care Cryotherapy: TechniquesTransition and Subacute Care Cryotherapy: Techniques

Cryokinetics

Combination of cold application and active exercise

Why Cryokinetics?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

Cryokinetics: DisadvantagesCryokinetics: Disadvantages

• Pain during initial session• Cold can be messy.

Cryokinetics: IndicationsCryokinetics: Indications

• Sprains—dynamite treatment– Ankle (especially)– Fingers

Cryokinetics: ContraindicationsCryokinetics: Contraindications

• Any exercise or activity that causes pain• Use of ice on a patient who is

hypersensitive to cold

Cryokinetics: PrecautionsCryokinetics: 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

Cryokinetics: OverviewCryokinetics: Overview

• Typically consists of five bouts of exercise interspersed with cold application for numbing

Cryokinetics Preapplication Tasks for Proper ModalityCryokinetics 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.

Cryokinetics Preapplication Tasks for Psychological PreparationCryokinetics Preapplication Tasks for Psychological Preparation

• Explain sensations• Cold very painful during first immersion.

– Adapt thereafter– Benefits of treatment outweigh temporary pain

Cryokinetics Preapplication Tasks for Physical PreparationCryokinetics Preapplication Tasks for Physical Preparation

• Remove clothing as necessary.• Position patient.

Cryokinetics Preapplication Tasks for Equipment PreparationCryokinetics Preapplication Tasks for Equipment Preparation

• Container and ice or ice pop• Toe cap is helpful.• Towels to sop up water

Cryokinetics Application to Numb Body PartCryokinetics Application to Numb Body Part

• Apply ice.– Immersion is best.

• 1°C water

– Use ice massage if cannot immerse.

Cryokinetics Application to Numb Body Part (cont.)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

Cryokinetics Application to Numb Body Part (cont.)Cryokinetics Application to Numb Body Part (cont.)

• Toe cap or sock keeps toes warm.

Cryokinetics Application forExercise

• 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.

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.

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.

Principles of Cryokinetics Exercise: Example (cont.)

• Non-weight-bearing ROM– Plantar flexion – Dorsiflexion – Inversion – Eversion – Circumduction

• Weight-bearing ROM– Stand up.– Shift weight

from foot to foot.– Gradually increase

weight on injured limb.

• Walk 1• Small steps• Heel to toe• Slow and deliberate

• No limp • No pain

Progress to . . .

• Walk 2 • Medium steps• Slow and deliberate• Then a little faster

• No limp• No pain

Progress to . . .

• Walk 3 • Large steps• Straight ahead • Around things or

in lazy S• Injured leg inside

and outside curveProgress to . . .

• Stretch heel cords, if necessary

• Strengthen muscles• Dorsiflexion, eversion, inversion• With Elgin ankle exerciser

Progress to . . .

• Jog• Straight ahead• Lazy S• Sharp Z• Work into running

Progress to . . .

• Four-square exercises

Principles of Cryokinetics Exercise:Example (cont.)

• Perform individual drills • With ankle taped

• ½ speed• ¾ speed• Full speed

• Perform team drills • With ankle taped

• ½ speed• ¾ speed• Full speed

Cryokinetics: SummaryCryokinetics: 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.

Cryokinetics: Summary (cont.)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

Cryokinetics: Application ParametersCryokinetics: 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.

Cryokinetics: Application Parameters (cont.)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

Cryokinetics Postapplication TasksCryokinetics 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.

Cryokinetics: MaintenanceCryokinetics: Maintenance

• Replace slush container when it cracks.• Sew sides of toe caps if they rip.

Cryostretch for Muscle InjuriesCryostretch 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.

Rehabilitation GoalsRehabilitation Goals

• Promote healing, if tissues torn.• Control pain.• Reduce spasm.• Control neural inhibition.

Rehabilitation Goals (cont.)Rehabilitation Goals (cont.)

• Reset central control through aggressive, progressive reorientation to full function.

• Develop muscle strength.• Promote other phases of rehabilitation as

explained earlier.

Begin with Cryostretch Begin with Cryostretch

Then transition into cryokinetics (for first- and second-degree injuries)

Cryostretch: FoundationCryostretch: Foundation

• Cold application• Static stretching • Hold–relax technique of PNF

• Combination of the muscle spasm reduction techniques

Ice Static stretch Isometric contraction

Cryostretch: Foundation (cont.)

Cryostretch: EffectsCryostretch: 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.

Combined procedure more effective than the sum of the three individual components

Ice inexpensive; exercise free

Cryostretch: AdvantagesCryostretch: Advantages

Ice is painful to some people. But massage not as painful as ice

immersion. Melting ice can be messy.

Cryostretch: DisadvantagesCryostretch: Disadvantages

Any muscle with residual, low-grade muscle spasm

Any first-degree muscle strain A muscle that is stiff from prolonged

disuse (immobilization) Do not confuse this with decreased

ROM owing to connective tissue contractures.

Cryostretch: IndicationsCryostretch: Indications

Any exercise or activity that causes pain Use of ice on a person who is

Cryostretch: ContraindicationsCryostretch: Contraindications

• 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: PrecautionsCryostretch: Precautions

• 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 ParametersCryostretch: Application Parameters

– 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.)Cryostretch: Application Parameters (cont.)

Numb/renumb

Isometric contractionStatic stretch

Cryostretch: Application Parameters (cont.)

First set Second set Third set

Second boutFirst bout

• 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)

Numb (20 min max), with ice massage Numb (20 min max), with ice massage

• 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.)Cryostretch: Application Parameters (cont.)

Cryostretch: First Bout, First Stretch

• 20 sec static stretch– Stretch muscle to limit; hold 20 sec

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.

Cryostretch: First Bout, Second Stretch

• 10 sec static stretch– Take up slack from first contraction.– Move to limits of tightness/pain.– Hold 10 sec.

Cryostretch: First Bout, Second Contraction

• 5 sec isometric contraction– Instruct patient to begin and end slowly, as

before.

Cryostretch: First Bout, Third Stretch

• 10 sec static stretch– Take up slack from second contraction.– Move to limits of tightness/pain.– Hold 10 sec.

Cryostretch: First Bout, Third Contraction

• 5 sec isometric contraction– Instruct patient to begin and end slowly, as

before.

Cryostretch: Between First and Second Bout

• Rest 20 sec

• Repeat first bout– 65 sec

Cryostretch: Second BoutCryostretch: Second Bout

Cryostretch: Second and Third Sets

• Renumb (5 min max)

• Repeat set

Numb/renumb

Isometric contractionStatic stretch

Cryostretch: Overall

•Use shoulder if patient is too big.•Use shoulder if patient is too big.

Cryostretch: Miscellaneous Tips

Cryostretch: Miscellaneous Tips (cont.)

• Stretch muscle until pain or tightness is felt, then back off until pain disappears.

Cryokinetics: Application Parameters RevisitedCryokinetics: 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.

Cryokinetics: Application Parameters Revisited (cont.)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

Cryokinetics: Postapplication Tasks RevisitedCryokinetics: 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.

Cryokinetics: Postapplication Tasks Revisited (cont.)Cryokinetics: Postapplication Tasks Revisited (cont.)

• Schedule the next treatment.• Record treatment, including unique patient

Cryokinetics: Maintenance RevisitedCryokinetics: Maintenance Revisited

• Replace slush container when it cracks.• Sew sides of toe caps if they rip.

Combined Cryostretch and CryokineticsCombined Cryostretch and Cryokinetics

• Begin once spasm begins to abate.– Often within 2–3 days

• Replace stretching with active (isotonic) exercise.

Combined Cryostretch and Cryokinetics (cont.)Combined Cryostretch and Cryokinetics (cont.)

• Begin and end with stretch.• Begin cryokinetics exercises with

manually resisted muscle contractions (6–10) through a full ROM.

Combined Cryostretch and Cryokinetics (cont.)

• Once strength begins to return (2–days), switch to some type of isotonic weight lifting

• Use DAPRE technique

Combined Cryostretch and Cryokinetics (cont.)

Progress through all phases of rehabilitation using progressive functional activities.

• 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 InjuryThe Last Word on Muscle Injury

Connective Tissue StretchConnective Tissue Stretch

• Technique to break tissue contractures• Used to increase joint flexibility after

prolonged immobilization

Connective Tissue Stretch:FoundationConnective Tissue Stretch:Foundation

• Combination of – Heat application – Long-term passive stretch– Cold applications

Connective Tissue Stretch:Foundation (cont.)Connective Tissue Stretch:Foundation (cont.)

• 45 min treatment

Connective Tissue Stretch:EffectsConnective 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.

Connective Tissue Stretch: AdvantagesConnective 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

Connective Tissue Stretch: DisadvantagesConnective Tissue Stretch: Disadvantages

• Boring treatment

Connective Tissue Stretch: IndicationsConnective Tissue Stretch: Indications

• Anytime connective tissue contractures prevent full ROM

Connective Tissue Stretch: ContraindicationsConnective Tissue Stretch: Contraindications

• Any exercise or activity that causes pain• Use of ice on a person who is

Connective Tissue Stretch: PrecautionsConnective Tissue Stretch: Precautions

• Avoid pain during stretching.– Usually occurs because resistance is too

Connective Tissue Stretch: AlternativesConnective Tissue Stretch: Alternatives

– Diathermy– Mobilization

Connective Tissue Stretch: Application ParametersConnective 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.

Connective Tissue Stretch: Application Parameters (cont).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.

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.

Connective Tissue Stretch: Application Parameters (cont.)Connective Tissue Stretch: Application Parameters (cont.)

• Dosage – As much resistance as comfortable

Connective Tissue Stretch: Application Parameters (cont.)Connective Tissue Stretch: Application Parameters (cont.)

• Length of application– 45 min per treatment session

• Duration of therapy– Until patient returns to full, unhindered activity.

Connective Tissue Stretch: Postapplication TasksConnective 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.

Connective Tissue Stretch: Postapplication Tasks (cont.)Connective Tissue Stretch: Postapplication Tasks (cont.)

Lymphedema PumpsLymphedema 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.

Lymphedema Pumps: FoundationLymphedema Pumps: Foundation

• Formerly called:– Intermittent compression pumps – Cold compression devices – Pneumatic compression pumps– Intermittent compression devices

Lymphedema Pumps: Foundation (cont.)Lymphedema Pumps: Foundation (cont.)

• Classified as:– Pneumatic (air)– Cryocompression (chilled water)– Circumferential (all at once)– Sequential (distal to proximal)

Lymphedema Pump: EffectsLymphedema 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.

Lymphedema Pump: AdvantagesLymphedema Pump: Advantages

• Requires minimal clinician time

Lymphedema Pump: DisadvantagesLymphedema Pump: Disadvantages

• Slow rate of boot/sleeve inflation• Tissue compression rate much faster

with active exercise and massage.

Lymphedema Pump: IndicationsLymphedema Pump: Indications

• Post-traumatic edema• Postoperative edema• Chronic edema• Primary and secondary lymphedema• Venous stasis ulcers• Persistent swelling from venous

insufficiency

Lymphedema Pump: ContraindicationsLymphedema 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

Lymphedema Pump: PrecautionsLymphedema Pump: Precautions

• Avoid pain during treatment.

Lymphedema Pump: AlternativesLymphedema Pump: Alternatives

• Active muscle activity• Massage

Lymphedema Pump: Preapplication TasksLymphedema Pump: Preapplication Tasks

• Same as cryokinetics preapplication tasks

Lymphedema Pump: Application ParametersLymphedema 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.

Lymphedema Pump: Application Parameters (cont.)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

Lymphedema Pump: Application Parameters (cont.)Lymphedema Pump: Application Parameters (cont.)

• Length of application– 20 min

• Duration of therapy– Until edema is resolved

Lymphedema Pump: Postapplication TasksLymphedema Pump: Postapplication Tasks

• Instructions to patient– Be active, as long as pain free

Lymphedema Pump: MaintenanceLymphedema Pump: Maintenance

• Periodically check hoses, valves, boots, and sleeves for leaks.

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

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