Cryotherapy Application for Post-Immediate Care: Decrease Pain and Facilitate Therapeutic Exercise

1. Chapter 13 Cryotherapy Application for Post–Immediate Care

2. 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 Transition and Subacute Care Cryotherapy

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

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

5. 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

6. 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 Water Immersion (cont.)

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

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

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

10. Cryokinetics • Combination of cold application and active exercise

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

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

13. Sprains—dynamite treatment Ankle (especially) Fingers Cryokinetics: Indications

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

15. 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 Cryokinetics: Precautions

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

17. 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 Proper Modality

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

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

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

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

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

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

24. 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 Application for Exercise

25. 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

26. 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

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

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

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

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

31. 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. Stretch heel cords, if necessary Principles of Cryokinetics Exercise: Example (cont.)

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

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

35. Principles of Cryokinetics Exercise: Example (cont.) • Four-square exercises

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

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

38. 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

39. 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: Summary (cont.)

40. 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

41. 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: Application Parameters (cont.)

42. 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. Cryokinetics Postapplication Tasks

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

44. 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. Cryostretch for Muscle Injuries

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

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

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

48. Cold application Static stretching Hold-relax technique of PNF Cryostretch: Foundation • Combinationof the muscle spasm • reduction techniques

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

50. 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. Cryostretch: Effects