4) Cryotherapy Use in Acute Care PDF

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KNES 377 - Cryotherapy Use in Acute Care...

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– Cryotherapy Use in Acute Care – Acute Care Myths – Acute care and immediate care are the same – Ice decreases swelling – The goal of immediate care is to decrease inflammation – The purpose of ice is to decrease hemorrhaging – Inflammation and swelling are the same – Ice should be applied for 20 min during immediate care – All injuries should be treated for the same amount of time – RICES – The prescription for acute care – Rest – Ice – Compression – Elevation – Stabilization – Why RICES? – To decrease: – Total injury – Swelling – Pain – Further injury – Muscle spasm – **DO NOT decrease inflammation – Why rest? – Limits injury aggravation – Should be total during immediate care – Transition to “relative” rest – Different from, but related to. Stabilization – Why ice? – Most think it’s to control swelling – Important but only a part of acute care – Limiting secondary injury and neural inhibition are more important

than controlling swelling – Cold decreases cellular metabolism in viable cells, thus – Reduces oxygen demand (consumption) – Less secondary hypoxic injury – Less total injury – Less free protein generated by phagocytosis

– Less edema – Metabolism and Cooling – Direct relationship – More cooling means greater decrease in metabolism – Heat increases metabolism – Causes more secondary injury – Cryotherapy and Swelling – Decreased edema, not hemorrhage – Most occurs hours after injury, as free protein accumulates

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from phagocytosis – Cold reduces edema formation – By preventing secondary injury and thus less free protein accumulation Why Compression? – Controls edema beyond normal volume – IE: After tissue spaces are filled – Apply constantly until swelling is over – Compression enhances cooling Why Elevation? – Decreases capillary hydrostatic pressure Why Stabilization? – Controls neural inhibition – Process in which neural pathway is blocked so impulses cannot pass – Intended function does not occur – Can be partial so function is diminished or total so function is abolished temporarily – Allows muscles to relax – Decreases pain-spasm-pain cycle – Numerous braces and splints for stabilization What is the goal of cold? – Decrease tissue metabolism – More cooling = greater decrease in metabolism Does it matter how you apply cold? – Yes; great differences in tissue cooling Energy Transfer – Conduction – Transfer via direct contact – IE: ice or heat pack on the skin – Convection – Transfer via movement of air or liquid

– IE: whirlpool or fluidotherapy – Radiation – Transfer from energy emitted from surfaces – IE: infrared lamps – Conversion – Energy changed from one form to another – IE: Ultrasound absorbed into tissues – Evaporation – IE: Sweating – Physiology of Heat Transfer – Conduction – Exchange of energy (heat) between two substances in

contact with each other – Heat moves from body of higher energy to body of lower energy – Causes warmer body to cool and cooler body to warm until equilibrium – Rate of Conduction Factors – Factors that influence rate of conduction – Temperature differential between body and modality – Heat storage capacity of cold modality – Size of the cold modality – Amount of tissue in contact – Length of application – Heat Storage Capacity – Latent heat of fusion – Amount of heat energy needed to convert a substance from a solid state to a liquid state without changing its temperature – Phase change – Ice to water = 80 cal/kg – Crushed ice pack better than gel pack – Temperature Changes Resulting from Cold Pack application – Surface temperature – Repeated applications – Time ratio – Activity between applications (shower) – Compression wrap over cold pack – Tissue temperature – Depends on depth and type of tissue – Delayed response – Continues to decrease after application

– Amount of adipose tissue – Rewarming takes hours – Factors that Effect Tissue Cooling – Type of cold pack – Heat of fusion – Duration of application – Longer the application – = more cooling – = slower rewarming – Size of cold pack – Larger cold pack = more cooling – Amount of tissue in contact with pack – More tissue contact = more cooling – Depth of target tissue – Deeper target = less cooling – Method of application – On skin, or over a towel/wrap – Compression over pack – Cryotherapy Use in Acute Care (cont.) – Types of cold packs (4 types) – Crushed Ice – Most effective (heat of fusion) – Excellent for on-the-field use because they don’t melt for

hours if stored in insulated cooler – Gel Pack – Water, alcohol, and gel substance – Cooled to ~1°F – Dangerous if applied directly on skin – Not as effective as crushed ice packs (no heat of fusion) – Less effective if wrapped in towel – Artificial Ice – Water in vinyl pouches, surrounded by nylon cover – Better than gel (heat of fusion) – Not as good as crushed ice because of insulation from nylon cover – Good for home use – Chemical – IE: double bags, crushable – Chemical reaction when inner bag is crushed and contents react with outer chemicals – Least cooling

– Not recommended – Cold: Application Protocol – If patient does not have any other health-related conditions

(diabetes, sensory impairment, circulation issue), apply directly to skin – EXCEPT for gel packs – Insulation decreases effectiveness – Length of Application – Intermittent, 30-60 min every 2 hours – Depth of target tissue – Adipose tissue – Duration of therapy – Severity of injury – Transition from RICES to cryotherapy techniques involving exercise – Preventing vs. Removing Swelling – Preventing secondary injury vs. removing free protein from extracellular spaces – Prevent: decrease metabolism – Cold effective – Remove: stimulate lymph flow – Cold is waste of time – How do we stimulate lymph flow? – Exercise!!! – Removing free protein from extracellular spaces – Must stimulate lymph flow – Requires intermittent compression – Massage – Lymphedema pump – Active exercise (muscle pump) – Compression: Application Principles – Elastic wraps preferred – Plastic wraps not as effective – Apply elastic wraps over ice pack – Compression same as if wrap applied first – Stretch elastic wraps ~75% as they are applied – Cryotherapy: Contraindications and Precautions ***IMPORTANT*** – Cold is dangerous if – Too cold or too long – Under excessive compression – Patient suffers from specific diseases

– Raynaud – Vascular disease characterized by a pale blue to red

sequence of color changes of the digits (common after exposure to cold) – Cause: Unknown – Cold hypersensitivity – Cold urticaria – Skin reaction to cold that appears within minutes after cold exposure (reddish, itchy welts) – Can lead to anaphylaxis shock – Cryotherapy in Acute Care – Effects: – Ice decreases metabolism in the injured tissue – Decreases the need for oxygen – Decreases secondary hypoxic injury – Compression and elevation – Counteract edema – Result in decreased swelling – Stabilization – Allows musculature around the injury to relax – Along with ice, limits pain-spasm-pain cycle – Advantages: – Less total tissue damage = less healing needed – Decreased swelling = less pain – Decreased pain = less neural inhibition – Ice is inexpensive – Disadvantages – Effectiveness diminishes with time – Best if applied 5-10 min after injury – Indications – Acute orthopedic or soft tissue injury – Decrease secondary injury – Decrease pain – Decrease muscle spasm – Precautions – Ice packs not directly on skin continuously for >60 min – Cold packs cooled to or less than −17°C(0°F) should not be applied directly to the skin – Applying cryotherapy directly over a peripheral nerve (e.g., lateral knee or medial elbow) – Length of Application

– Ice bag, intermittently – 20–60 min depends on injury and skinfold – 20 min, finger – 30 min ankle, arm – 45 min, thigh – +1 min per millimeter of skinfold – Compression and elevation constantly – Rest and stabilization until pain free – Frequency of Application – Ice – 5–10 min after injury – Second application 30–60 min later, after shower and go

home – Every 2 hr thereafter (don’t stay up into night) – Rest, compression, elevation, and stabilization constantly – Thermotherapy – Thermotherapy Modalities – Deciding between hot and cold (If all are NO, then heat can be

used; Yes increases = indication of cold usage increases) – Does the body area feel warm to the touch? – Is the injured area still sensitive to light to moderate touch? – Does the amount of swelling continue to increase over time? – Does swelling increase during activity? – Does pain limit the joint’s ROM? – Is the acute inflammation process still active? – Does the patient continue to display improvement with the use of cryotherapy? – Transitioning from Cryo- to Thermotherapy – Acute Inflammatory Phase – Rest – Cryotherapy – Compression – Elevation – In-Between Phases – Cryokinetics – Cryotherapy – Proliferation Phase – Thermotherapy – Exercise – Cryokinetics

– Combines cryotherapy with exercise – Cryokinetics is used to improve motion by eliminating or reducing

pain – Should be used when pain is limiting factor in functional movement and underlying soft-tissues are intact – Idea is to numb injured part (10-12 min) then work toward achieving normal ROM through progressive active exercise – Numbness usually last for 3-5 min. at which point ice is reapplied for 3-5 minutes until numbness returns – Repeated five times – Cryokinetics – Exercises should be pain free and progressive in intensity concentrating on both flexibility and strength – Benefits – Quicker macrophage reaction – Quicker hematoma resolution – Increased vascular growth – Increased tensile strength of healed muscle – Thermotherapy Modalities – Physiologic Effects of Tissue Heating – Used to produce an analgesic effect through gate control and by decreasing spasm – Heat is applied in musculoskeletal and neuromuscular disorders – Increases the elasticity and decreases the viscosity of connective tissue – Most frequent indication for the use – Basically...warm it up before you do flexibility/ROM exercises – Produces a relaxation effect and a reduction in muscle guarding by: – Relieving pain – Lessening hypertonicity of muscles – Producing sedation – Decreasing spasticity, tenderness, and spasm – Warm Whirlpool – Temperature Range – Upper Extremity 98°-110° F – Lower Extremity 98°-104° F – Full body 98°-102° F – Time of application should be 10-15 minutes – Disadvantage: – Cost; Space

– Whirlpool maintenance and calibration – Hydrocollator Packs (i.e., Hot Packs) – Canvas pouches of petroleum distillate – Water temperature 170° – 6 layers ( or 1”) of toweling recommended – Don’t lie on top of hot pack – Time of application should be 10-15 minutes – Infrared Lamps – Superficial tissue temperature can be increased even though unit

does not touch patient – Seldom used because of limited depth of skin penetration < 1 mm – Moist towels should cover the area to be treated – Ultrasound (depending on parameters chosen) – Can create a deeper heat (5cm) to tissues than heat pack (1-2cm) – Therapeutic Effect – Increased blood flow – Increased tissue extensibility – Decreased pain• – Indications – Muscle spasm – Scar tissue – Joint contracture – Contraindications – Impaired circulation – Over areas of DVT (deep vein thrombosis) – Over fracture site – Precautions – Over epiphyseal plates of growing bone – Metal implants...