Transcript Example (cont.) - Wolters Kluwer Health

Chapter 13
Cryotherapy Application for
Post–Immediate Care
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Transition and Subacute Care Cryotherapy
• Begin once secondary injury stops
• Usually within 24 h
• Used for very different reasons than during immediate
care
– Decrease pain and inhibition
– Facilitate pain-free therapeutic exercise
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Transition and Subacute Care Cryotherapy
(cont.)
• Application types and times differ
• The key: exercise, not the cold
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Local Numbing with Cryotherapy
• Ice water immersion
• Ice massage
• Ice bag (occasionally)
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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.
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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
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Ice Massage
• Slowly stroke muscle with
ice pop.
• Discontinue when numb.
• Adding a plate weight will
increase numbness.
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Ice Massage (cont.)
• Prepare ice pops by
– Freezing water in
6–8 oz. paper cups
– Add tongue
depressor to some
for handle.
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Transition and Subacute Care
Cryotherapy: Techniques
•
•
•
•
Cryokinetics
Cryostretch
Contrast bath
Connective tissue stretch
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Cryokinetics
• Combination of cold application and active exercise
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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
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Cryokinetics: Disadvantages
• Pain during initial session
• Cold can be messy.
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Cryokinetics: Indications
• Sprains—dynamite treatment
– Ankle (especially)
– Fingers
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Cryokinetics: Contraindications
• Any exercise or activity that causes pain
• Use of ice on a patient who is hypersensitive to cold
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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 h after treatment
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Cryokinetics: Overview
• Typically consists of five bouts of exercise interspersed
with cold application for numbing
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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.
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Cryokinetics Preapplication Tasks for
Psychological Preparation
• Explain sensations.
• Cold very painful during first immersion.
– Adapt thereafter
– Benefits of treatment outweigh temporary pain.
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Cryokinetics Preapplication Tasks for
Physical Preparation
• Remove clothing as necessary.
• Position patient.
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Cryokinetics Preapplication Tasks for
Equipment Preparation
• Container and ice or ice pop
• Toe cap is helpful.
• Towels to sop up water
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Cryokinetics Application to Numb Body Part
• Apply ice.
– Immersion is best.
• 1°C water
– Use ice massage if
cannot immerse.
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Cryokinetics Application to Numb Body
Part (cont.)
• Apply until body part is numb.
– Usually 10–20 min
– Goal is numbness, not the time.
– Stop application after 20 min whether or not
patient feels numb.
• Some people (10–20%) cannot tell when they
are numb.
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Cryokinetics Application to Numb Body Part
(cont.)
• Toe cap or sock keeps toes warm.
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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.
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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.
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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.
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Principles of Cryokinetics Exercise:
Example (cont.)
• Non-weight-bearing ROM
– Plantar flexion
– Dorsiflexion
– Inversion
– Eversion
– Circumduction
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Principles of Cryokinetics Exercise:
Example (cont.)
• Weight-bearing ROM
– Stand up.
– Shift weight
from foot to foot.
– Gradually increase
weight on injured limb.
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Principles of Cryokinetics Exercise:
Example (cont.)
Walk 1
– Small steps
– Heel to toe
– Slow and deliberate
• No limp
• No pain
Progress to …
•
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Principles of Cryokinetics Exercise:
Example (cont.)
Walk 2
• Medium steps
• Slow and deliberate
• Then a little faster
• No limp
• No pain
Progress to …
•
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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 …
•
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Principles of Cryokinetics Exercise:
Example (cont.)
• Stretch heel cords, if
necessary
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Principles of Cryokinetics Exercise:
Example (cont.)
•
Strengthen muscles
– Dorsiflexion, eversion, inversion
– With Elgin ankle exerciser
Progress to …
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Principles of Cryokinetics Exercise:
Example (cont.)
Jog
• Straight ahead
• Lazy S
• Sharp Z
• Work into running
Progress to . . .
•
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Principles of Cryokinetics Exercise:
Example (cont.)
•
Four-square exercises
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Principles of Cryokinetics Exercise:
Example (cont.)
• Perform individual drills
– With ankle taped
• ½ speed
• ¾ speed
• Full speed
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Principles of Cryokinetics Exercise:
Example (cont.)
• Perform team drills
– With ankle taped
• ½ speed
• ¾ speed
• Full speed
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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.
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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
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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.
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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
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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 h; if so, apply an ice pack for
30 min.
• Schedule the next treatment.
• Record treatment, including unique patient responses.
• Clean up area.
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Cryokinetics: Maintenance
• Replace slush container when it cracks.
• Sew sides of toe caps if they rip.
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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.
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Rehabilitation Goals
•
•
•
•
Promote healing, if tissues torn.
Control pain.
Reduce spasm.
Control neural inhibition.
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Rehabilitation Goals (cont.)
• Reset central control through aggressive, progressive
reorientation to full function.
• Develop muscle strength.
• Promote other phases of rehabilitation as explained
earlier.
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Begin with Cryostretch
Then transition into cryokinetics (for first- and seconddegree injuries)
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Cryostretch: Foundation
• Combination of the muscle spasm
reduction techniques
• Cold application
• Static stretching
• Hold-relax technique of PNF
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Cryostretch: Foundation (cont.)
Ice
Static stretch
Isometric contraction
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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.
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Cryostretch: Advantages


Combined procedure more effective than the sum of
the three individual components
Ice inexpensive; exercise free
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Cryostretch: Disadvantages


Ice is painful to some people.
– But massage not as painful as ice
immersion.
Melting ice can be messy.
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Cryostretch: Indications



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.
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Cryostretch: Contraindications


Any exercise or activity that causes pain
Use of ice on a person who is hypersensitive to cold
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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 h after
treatment.
• Isometric contractions must begin and end
gradually.
– Sudden starts or stops may tear muscle fibers.
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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)
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Cryostretch: Application Parameters
(cont.)
– 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
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Cryostretch: Application Parameters
(cont.)
Numb/renumb
Static stretch
Isometric contraction
First bout Second bout
First set
Second set
Third set
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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)
Renumb
Two more stretching bouts (20 sec rest)
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Cryostretch: Application Parameters
(cont.)
• Numb (20 min max), with ice massage
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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.
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Cryostretch: First Bout, First Stretch
• 20 sec static stretch
– Stretch muscle to limit; hold 20 sec.
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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.
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Cryostretch: First Bout, Second Stretch
• 10
–
–
–
sec static stretch
Take up slack from first contraction.
Move to limits of tightness/pain.
Hold 10 sec.
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Cryostretch: First Bout, Second
Contraction
• 5 sec isometric contraction
– Instruct patient to begin and end slowly, as
before.
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Cryostretch: First Bout, Third Stretch
• 10
–
–
–
sec static stretch
Take up slack from second contraction.
Move to limits of tightness/pain.
Hold 10 sec.
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Cryostretch: First Bout, Third
Contraction
• 5 sec isometric contraction
– Instruct patient to begin and end slowly, as
before.
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Cryostretch: Between First and Second
Bout
• Rest 20 sec
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Cryostretch: Second Bout
• Repeat first bout
– 65 sec
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Cryostretch: Second and Third Sets
• Renumb (5 min max)
• Repeat set
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Cryostretch: Overall
Numb/renumb
Static stretch
Isometric contraction
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Cryostretch: Miscellaneous Tips
• Use shoulder if patient is too big.
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Cryostretch: Miscellaneous Tips (cont.)
• Stretch muscle until pain or tightness is
felt, then back off until pain disappears.
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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.
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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
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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 h; if so, apply an ice pack for
30 min.
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Cryokinetics: Postapplication Tasks
Revisited (cont.)
• Schedule the next treatment.
• Record treatment, including unique patient responses.
• Clean up area.
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Cryokinetics: Maintenance Revisited
• Replace slush container when it cracks.
• Sew sides of toe caps if they rip.
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Combined Cryostretch and Cryokinetics
• Begin once spasm begins to abate.
– Often within 2–3 days
• Replace stretching with active (isotonic) exercise.
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Combined Cryostretch and Cryokinetics
(cont.)
• Begin and end with stretch.
• Begin cryokinetics exercises with manually
resisted muscle contractions (6–10) through a full
ROM.
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Combined Cryostretch and Cryokinetics
(cont.)
• Once strength begins to return (2–days), switch to
some type of isotonic weight lifting.
• Use DAPRE technique.
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Combined Cryostretch and Cryokinetics
(cont.)
Progress through all phases of rehabilitation using
progressive functional activities.
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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.
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Connective Tissue Stretch
• Technique to break tissue contractures
• Used to increase joint flexibility after prolonged
immobilization
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Connective Tissue Stretch:
Foundation
• Combination of
– Heat application
– Long-term passive stretch
– Cold applications
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Connective Tissue Stretch:
Foundation (cont.)
• 45 min treatment
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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.
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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
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Connective Tissue Stretch:
Disadvantages
• Boring treatment
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Connective Tissue Stretch: Indications
• Anytime connective tissue contractures prevent full
ROM
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Connective Tissue Stretch:
Contraindications
• Any exercise or activity that causes pain
• Use of ice on a person who is hypersensitive to cold
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Connective Tissue Stretch: Precautions
• Avoid pain during stretching.
– Usually occurs because resistance is too great
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Connective Tissue Stretch: Alternatives
– Diathermy
– Mobilization
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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.
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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.
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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.
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Connective Tissue Stretch:
Application Parameters (cont.)
• Dosage
– As much resistance as comfortable
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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
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Connective Tissue Stretch:
Postapplication Tasks
• Instructions to the patient
– Be active, as long as pain free.
– May feel pain in 4–8 h; if so, apply an ice pack for
30 min.
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Connective Tissue Stretch:
Postapplication Tasks (cont.)
• Schedule the next treatment.
• Record treatment, including unique patient responses.
• Clean up area.
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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.
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Lymphedema Pumps: Foundation
• Formerly called:
– Intermittent compression pumps
– Cold compression devices
– Pneumatic compression pumps
– Intermittent compression devices
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Lymphedema Pumps: Foundation (cont.)
• Classified as:
– Pneumatic (air)
– Cryocompression (chilled water)
– Circumferential (all at once)
– Sequential (distal to proximal)
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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.
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Lymphedema Pump: Advantages
• Requires minimal clinician time
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Lymphedema Pump: Disadvantages
• Slow rate of boot/sleeve inflation
• Tissue compression rate much faster with
active exercise and massage.
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Lymphedema Pump: Indications
•
•
•
•
•
•
Post-traumatic edema
Postoperative edema
Chronic edema
Primary and secondary lymphedema
Venous stasis ulcers
Persistent swelling from venous insufficiency
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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
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Lymphedema Pump: Precautions
• Avoid pain during treatment.
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Lymphedema Pump: Alternatives
• Active muscle activity
• Massage
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Lymphedema Pump:
Preapplication Tasks
• Same as cryokinetics preapplication tasks
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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.
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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
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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
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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.
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Lymphedema Pump:
Maintenance
• Periodically check hoses, valves, boots, and sleeves
for leaks.
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