COLD PACKS OR ICE PACKSEquipment Required• Towels or pillow cases for hygiene and/or insulation• For cold packs• Cold packs in a variety of sizes and shapes appropriate fordifferent areas of the body• Freezer or specialized cooling unit• For ice packs• Plastic bags• Ice chips• Ice chip machine or freezerProcedure1. Remove all jewelry and clothing from the area to be treatedand inspect the area.2. Wrap the cold pack or ice pack in a towel. Use a damp towel ifa maximal rate of tissue cooling is desired. It is recommendedthat warm water be used to dampen the towel to allow thepatient to gradually become accustomed to the cold sensation.A thin, dry towel can be used if slower, less intense cooling isdesired. A damp towel is generally appropriate for a cold pack,whereas a dry towel should be used for an ice pack because iceprovides more intense cooling.3. Position the patient comfortably, elevating the area to betreated if edema is present.4. Place the wrapped pack on the area to be treated, and secureit well. Packs can be secured with elastic bandages or towels toensure good contact with the patient’s skin.5. Leave the pack in place for 10 to 20 minutes to control pain,inflammation, or edema. When cold is applied over bandagesor a cast, application time should be increased to allow thecold to penetrate through these insulating layers to the skin.78In this circumstance, the cold pack should be replaced with a

newly frozen pack if the original pack melts during the courseof the intervention.If cryotherapy is being used to control spasticity, the packshould be left in place for up to 30 minutes. With these longerapplications, check every 10 to 15 minutes for any signs of adverseeffects.6. Provide the patient with a bell or other means to call forassistance.7. When the intervention is completed, remove the pack and inspectthe treatment area for any signs of adverse effects suchas wheals or a rash. It is normal for the skin to be red or darkpink after icing.8. Cold or ice pack application can be repeated every 1 to2 hours to control pain and inflammation.79Advantages• Easy to use• Inexpensive materials and equipment• Brief use of clinician’s time• Low level of skill required for application• Covers moderate to large areas• Can be applied to an elevated limbDisadvantages• Pack must be removed for the treatment area to be visualizedduring treatment.• Patient may not tolerate the weight of the pack.• Pack may not be able to maintain good contact on small orcontoured areas.• Long duration of treatment compared with massage with anice cup.Ice Pack Versus Cold Pack• Ice pack provides more intense cooling.• Ice pack is less expensive.• Cold pack is quicker to apply.

ICE MASSAGEEquipment Required• Small paper or Styrofoam cups• Freezer• Tongue depressors or popsicle sticks (optional)• Towels to absorb waterProcedure1. Remove all jewelry and clothing from the area to be treatedand inspect the area.2. Place towels around the treatment area to absorb any drippingwater and to wipe away water on the skin during treatment.3. Rub ice over the treatment area using small, overlapping circles.Wipe away any water as it melts on the skin.4. Continue ice massage application for 5 to 10 minutes, or untilthe patient experiences analgesia at the site of application.5. When the intervention is completed, inspect the treatmentarea for any signs of adverse effects such as wheals or a rash.It is normal for the skin to be red or dark pink after the applicationof ice massage. Ice massage may be applied in thismanner for local control of pain, inflammation, or edema. Icemassage can also be used as a stimulus for facilitating theproduction of desired motor patterns in patients withimpaired motor control. When applied for this purpose,the ice may be rubbed with pressure for 3 to 5 seconds orquickly stroked over the muscle bellies to be facilitated.This technique is known as quick icing.Advantages• Treatment area can be observed during application.

• Technique can be used for small and irregular areas.• Short duration of treatment• Inexpensive• Can be applied to an elevated limbDisadvantages• Too time-consuming for large areas• Requires active participation by the clinician or the patientthroughout application

CONTROLLED COLD COMPRESSIONEquipment Required• Controlled cold compression unit• Sleeves appropriate for area(s) to be treated• Stockinette for hygieneProcedure1. Remove all jewelry and clothing from the area to be treatedand inspect the area.2. Cover the limb with a stockinette before applying the sleeve.3. Wrap the sleeve around the area to be treated.4. Elevate the area to be treated.5. Set the temperature at 10° C to 15° C (50° F to 59° F).6. Cooling can be applied continuously or intermittently. Forintermittent treatment, apply cooling for 15 minutes every2 hours.7. Cycling intermittent compression may be applied at all timeswhen the area is elevated.8. When the intervention is completed, remove the sleeve andinspect the treatment area.Advantages• Allows simultaneous application of cold and compression• Temperature and compression force are easily and accuratelycontrolled.• Can be applied to large jointsDisadvantages• Treatment site cannot be visualized during treatment.• Expensive• Usable only for extremities• Cannot be used for trunk or digits

VAPOCOOLANT SPRAY AND BRIEF ICINGProcedure1. Identify trigger points and their related tight muscles.2. Position the patient comfortably, with all limbs and the backwell supported and the area to be treated exposed and accessible.Inspect the area to be treated. Cover the patient’s eyes,nose, and mouth if spraying near the face, to minimize thepatient’s inhalation of the spray.3. Apply two to five parallel sweeps of the spray or strokes of theice 1.5 to 2 cm (0.5 to 1 inch) apart at a speed of approximately10 cm (4 inches) per second along the direction of themuscle fibers. When using a spray, hold the can upright about30 to 46 cm (12 to 18 inches) from the skin and angled so thatthe spray hits the skin at an angle of about 30 degrees. Continueuntil the entire muscle has been covered, including themuscle attachment and the trigger point.4. During cooling, maintain gentle, smooth, steady tension onthe muscle to take up any slack that may develop.5. Immediately after cooling, have the patient take a deepbreath and then perform a gentle passive stretch whileexhaling. Contraction/relaxation techniques may be usedto enhance the ROM increases obtained with this procedure.6. Following this procedure, the skin should be rewarmed withmoist heat, and the muscles should be moved through theirfull active ROM (AROM).Advantages• Brief duration of cooling• Very localized area of applicationDisadvantages• Limited to use for brief, localized, superficial application of coldbefore stretching• Other means of applying cryotherapy

DOCUMENTATIONThe following should be documented:• Area of the body treated• Type of cooling agent used• Treatment duration• Patient positioning• Response to the interventionDocumentation is typically written in the SOAP(Subjective, Objective, Assessment, Plan) note format.The following examples only summarize the modalitycomponent of the intervention and are not intended torepresent a comprehensive plan of care.EXAMPLESWhen applying an ice pack (IP) to the patient’s (pt) left (L)knee to control postoperative (postop) swelling, documentthe following:S: Pt reports postop L knee pain and swelling that increases withwalking.O: Pretreatment: Midpatellar girth 161⁄2 in. Gait “step to” whenascending stairs.Intervention: IP L anterior knee for 15 min, L LE elevated.Posttreatment: Midpatellar girth 15 in. Gait “step through” whenascending stairs.A: Decreased midpatellar girth, improved gait.P: Instruct pt in home program of IP to L anterior knee, 15 min,with L LE elevated, 33 each day until next treatment session.When applying ice massage (IM) to the area of the right(R) lateral (lat) epicondyle to treat epicondylitis, documentthe following:S: Pt reports pain in R lat elbow.O: Pretreatment: 8/10 R lat elbow pain. R elbow unable to fully extend.Intervention: IM R lat elbow for 5 min.Posttreatment: Pain 6/10. Full elbow extension.A: Pain decreased and elbow ROM improved.P: Continue IM at end of treatment sessions until pt haspain-free elbow function.