The Forgotten Art

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March 2002

By Leslie J. Lear, MS, PT, ATC, CSCS, and Thomas W. Kaminski, PhD, ATC/L

Thomas W. Kaminski, PhD, ATC/L, applies an ice massage to Whitney Saller, an injured athlete, prior to functional activity.

While submersed in a warm extremity whirlpool, Saller performs range-of-motion exercises.

Rediscovering the efficacy of cryotherapy

Cryotherapy, the therapeutic application of a substance to the body for the purpose of removing heat and decreasing tissue temperature, has been around since the beginnings of medicine.1 Considering the well-established efficacy of cold therapy, one has to wonder why we, the experts in therapeutic modalities and rehabilitation, have allowed ourselves to simplify and devalue its importance. Cryotherapy is much more than merely throwing a bag of ice on an injured body part in hopes of making our patients feel better or buying us some time in the clinic when we are double or triple booked.

Why do we allow ourselves to minimize cryotherapy to nothing more than this? Perhaps it is because we have allowed others, like insurance companies, to tell us that cryotherapy is an unskilled and unnecessary treatment that is most certainly undeserving of reimbursement. After all, anyone can set a timer for 15 minutes, take a bag of frozen peas out of the freezer, and drape it across a shoulder, right?

Wrong. Cryotherapy is more than a rote skill. It is an art and the rehabilitation specialist is the artist. The expression of one's artistic talents is limited only by the ingenuity and imagination of the artist. One style of cryotherapy, cryokinetics, is perhaps the best example of physiologically sound creativity in the art of rehabilitation.

Cryotherapy's Role In Rehab
The therapeutic benefits of cold post-acute injury, postoperatively, and during rehabilitation are well documented.^1-3 The physiological effects of cold include a decrease in tissue temperature and metabolism. Circulation is also decreased as a result of vasoconstriction and increased blood viscosity.^1,2 Increased tissue and synovial fluid viscosity will create muscle stiffness and slightly impair muscular efficiency.⁴ Pain and muscle spasms are reduced as a result of cryotherapy's effect on the nervous system. Cold reduces the rate of firing in nerves to the point that sensory nerve conduction is blocked and thermal anesthesia or numbness is experienced.^1,2 In addition to decreasing sensory and motor nerve conduction velocity, cryotherapy decreases pain through the stimulation of endorphin release, reduction in metabolism, and counterirritation.¹ Furthermore, the decrease in sensory input inhibits the stretch reflex and aids in reducing muscle spasms.

According to Knight, a reduction in metabolism to healthy tissues surrounding the injured area is beneficial in order to prevent secondary hypoxia.¹ Following acute injury, the buildup of fluid and proteins and increased interstitial pressure create edema, which compromises circulatory integrity, placing the surrounding tissues at risk for hypoxia. Slowing tissue metabolism reduces energy and, therefore, oxygen requirements of the surrounding tissues, enabling them to survive without hypoxic damage.¹

In terms of motor performance, sensory changes will result in a decrement in manual dexterity and fine motor activity.⁴ However, most skilled, gross motor tasks performed immediately following cold application will not be impaired.¹

There is a multitude of cryotherapy modalities available including the ice pack, cold pack, ice massage, cold whirlpool, cryocuff, cold spray, cryostretch, and cryokinetics, the combination of cryotherapy and exercise to restore pain-free function. More simply, cryokinetics can be considered cold and motion.⁵ Cryokinetics consists of numbing an injured body part to allow the patient to tolerate progressive, active exercise.¹ This active exercise is subsequently followed by reapplication of cold and the series is repeated a number of times. Cryokinetics dates back to the 1960s when rehabilitation specialists at Brooks Army Medical Hospital reported an 80% success rate in returning soldiers to unrestricted duty within 3 days of implementing an aggressive cryokinetic program.^2,5

Indications and Advantages
Perhaps the most appropriate use of cryokinetics is treating patients with acute joint sprains in which range of motion (ROM), weight-bearing tolerance, and functional activity tolerance are limited by pain and edema. Following an acute injury, pain often restricts motion, which prevents patients from returning to their work or sport. Cryokinetics speeds the recovery process by enabling patients to participate in pain-free controlled mobilization sooner than would normally be tolerated.³ As previously discussed, cryotherapy decreases pain to allow the patient to receive the benefits of active motion that may otherwise not be tolerated. The muscle-pumping action of active motion aids in removal of dead tissue, pain-inducing substances, and excess fluid lingering at the injured site. Knight reports this active pump is aided by exercise-induced vasodilatation brought about that actually surpasses circulatory increases stimulated by the application of therapeutic heat.¹ Furthermore, tissue gliding during early mobilization minimizes the risk of adhesions while concurrently facilitating scar tissue remodeling. Finally, active motion helps the patient overcome the neural inhibition that frequently accompanies postinjury pain and inflammation.¹

Cryokinetics is relatively inexpensive and easy to implement. Therefore, it is practical for almost every rehabilitation setting. Depending on the mode of cryotherapy chosen, equipment needs may include: buckets, basins or whirlpools, ice that is preferably crushed, cold packs, ice bags or frozen ice cups, towels, a rubber mat or nonslip surface, and toe or finger caps if needed. Therapeutic equipment needs vary depending on the individualized exercise progression.

Treatment Guidelines
Step one: Prior to initiating treatment, the patient must be given a thorough explanation of the purpose and expectations involved with cryokinetics. Patients must be forewarned of the discomfort associated with cryotherapy while concurrently emphasizing the temporary necessity of the pain in order to achieve the desired outcome.

Step two: Patients must be instructed on how to differentiate among the different types of pain and discomfort that they may experience during the treatment.¹ They need to be able to choose from preexisting pain, which is a result of their injury or pathology; cold-induced pain, which is due to the cold application as a result of the sensory changes that occur, ie, the numbing process, which begins with initial pain secondary to increased sensory stimulation, followed by a burning and aching, and, eventually, anesthesia^1,2,5; and exercise-induced pain, which suggests that the activity of an anesthetized foot may mean the exercise is inducing additional tissue damage.¹ Pain-free motions are crucial during the exercise component of cryokinetics. Exercise-induced pain is a signal to the rehabilitation specialist that the particular exercise is too strenuous and needs to be modified if possible or discontinued. The patient must take care to differentiate between the return of prenumbing discomfort and exercise-induced pain.

Step three: Treatment is initiated by numbing the body part with a chosen method of cryotherapy. Ice immersion, ice water buckets or whirlpools, ice massage, and cold packs are all considered acceptable means in cryokinetics.^1,2 The length of time for the cold application varies depending on the modality chosen and the body part being treated. The patient's self-report of numbness, determined by a loss of tactile sensation, serves as the guide for time. The initial numbing takes anywhere from 10 to 20 minutes during the first cold application.^1,5 Subsequent cooling to renumb the body part will last less than 5 minutes in most cases.¹

Step four: Once numbness is established, pain-free and progressive, active exercise may commence. Each exercise bout will last approximately 2 to 3 minutes until the numbness begins to wear off and sensation returns.² Patients should attempt to perform five to six sets of active exercise, separated by cold application to restore numbness. Exercise progressions in cryokinetics are similar to those in more traditional therapeutic exercise programs.¹

Exercise-Specific Guidelines
Non-weight-bearing, pain-free, active ROM should start with single plane and progress to multiplanar motions. For the patient with back pain, postural repositioning and active-assisted stretching may also be introduced in this initial stage.

The initiation of weight-bearing exercises includes a progressive shifting from partial weight bearing to full weight bearing unilaterally on the involved lower extremity (LE). Weight-bearing activities can also be introduced into upper extremity (UE) cryokinetics by having the patient lean on a table or wall.

c) ROM exercises in weight bearing are introduced, including but not limited to closed kinetic chain exercises (CKCE) such as: calf raises, squats, wall push-ups, biomechanical ankle platform board exercises, and therapeutic ball exercises. Depending on the involved body part, weight-bearing stretches such as a standing gastroc-soleus stretch may be incorporated into this phase of rehabilitation if the patient has not achieved full ROM.¹

Progression to ambulation, cycle ergometry, stair climbing, and ramps should proceed cautiously with a strong emphasis on proper form. A patient not yet tolerating full weight bearing may induce additional tissue damage if exercises are progressed too quickly and performed incorrectly. LE activities should be performed with both shoes off, as a self-imposed leg length discrepancy may contribute to faulty biomechanics and induced additional damage. Furthermore, caution must be taken during LE cryokinetics to assure that the limb is adequately dried before exercise sets and activities are performed on a nonslip surface such as a rubber mat. Progressions within this stage may include increasing the speed or resistance and introducing directional changes.¹

Resistive ROM exercises are implemented to restore muscular strength and power and may consist of progressive resistive exercises (PREs) using weights, bands, or other available equipment. Pain-free heel walking and toe walking utilize the patient's body weight as resistance in a safe and controlled manner.

Progression into functional sport or work specific activities should be introduced into the cryokinetic program at safe intensities, prior to attempting them at preinjury intensities. High speed walking may progress to straight line jogging, and then incorporate wide arc turns and figure eights, progressing to pivoting and cutting, as tolerated. Dynamic exercises such as multidirectional shuffles, carioca, and grapevine drills, conservatively introduced by allowing patients to watch their feet, may be progressed by requiring the patients to look straight ahead instead of down at the floor. For athletes, running speed can be increased until they can tolerate short sprints. Hopping and jumping drills for LE patients may range from simple to complicated in order to meet the given patient's functional goals. By utilizing tape markers on the floor, basic side-to-side and forward-backward hops, progressing to diagonal hops, may be performed in addition to straight-line and cross-over hopping drills.¹ Agility drills including the shuttle run, t-test, or Edgren side step are also appropriate at this level of rehabilitation. A word of caution must be made regarding safety. During these higher-level functional drills, an ankle patient will most likely be barefoot as stopping to dry off and put on a shoe will significantly infringe on the 3-minute window of opportunity available before the numbness wears off. Therefore, the rehabilitation specialist must determine if the lack of adequate support places the patient at too great a risk to engage in these exercises.

Step five: As numbness wears off, patients' sensation of their injury or pathology induced pain in their feet will return. This is the signal to reapply the cold and renumb the affected area. Renumbing generally takes between 3 and 5 minutes.^1,2

Step six: The focus of cryokinetic documentation should be on the amount of time spent and the description of the individual exercises. Keeping in mind that the exercise set is time-dependent due to rapid re-warming, one should not become overly concerned with counting repetitions as this is cumbersome and unnecessary. Progression can be objectively recorded as an increase in demonstrated ROM, weight- bearing tolerance, or movement speed. Functional progress is demonstrated through the documented advancement from basic functional skills such as ambulating, to the more complicated, sport-specific skills like sprinting and jumping.

Step seven: The final phase of cryokinetics involves allowing the numbness to wear off while functional activity continues. This enables the rehabilitation specialist to assess the patient's activity tolerance and determine readiness to progress beyond cryokinetics. At this stage, sport or work specific activities can be performed in more realistic settings such as the practice field or a work simulation station. During this phase, equipment needs such as bracing or taping, in addition to shoes, may be utilized to increase safety and support.

wrapping up Ideally, cryokinetics should be performed two to three times a day for the patient whose main goal is to return to sport or work as soon as safely possible. For an outpatient therapist practicing in a clinic setting, this may not be possible. However, this challenge may be readily overcome by teaching patients how to carry out the cryokinetic program at home. Equipment needs beyond an adequate quantity of ice are minimal, as the patient can use body weight through CKCE for the resistive component of the home program. The need for proper form and pain-free motion cannot be stressed enough to the patient carrying through with the home program. In the sports setting, the athletic trainer can readily carry out the treatments. Likewise, for a therapist working in an inpatient hospital facility treating postoperative patients or running an outpatient work hardening program, cryokinetic treatments two to three times daily are realistic and strongly encouraged.

Unfortunately, not all patients are appropriate for cryokinetics. Insensitivity to cold must be identified in the initial screening process of the patient. Psychological intolerance to the cryotherapy can be minimized or avoided by communicating the expected cold intensity to the patient. Explain to patients how the initial treatment is always the least comfortable, as their body will quickly adapt and become less sensitive to all subsequent cold treatments.¹ The utilization of toe or finger caps on the ankle and wrist patient will decrease discomfort in these highly cold-sensitive areas. Engaging the patient in distraction techniques during cryotherapy is also recommended to prevent psychological intolerance.²

The suitability of cryokinetics for a given patient depends on the location and extent of the injury. For example, following a minor ankle sprain, cryokinetics can be initiated within the first 24 to 48 hours.³ However, more severe joint sprains may render the patient very unstable and, therefore, an unsafe candidate for the progressive nature of cryokinetics.

Turn Up the Heat
For the patient exhibiting psychological intolerance to cryo- kinetics, contrast baths combined with active exercise may be a treatment alternative.

Traditionally, contrast baths consisted of alternating between immersion of the injured body part in hot (106°F) and cold (50°F) water over a period of 20 to 30 minutes.6 Immersion time is typically 3 minutes of hot followed by 1 minute of cold. The comforting sensation of the warm water, combined with the limited exposure to the cold water, may enable cold-intolerant patients to initiate active exercises earlier in their rehabilitation program. The kinetic component of cryokinetics can be incorporated into contrast baths by adding active exercises, similar to those described under cryo-kinetics as the third step, immediately following the 1-minute cold immersion just prior to reimmersion into the hot water. This three-step cycle would then be repeated over a series of four to five times, ending the treatment with cold water immersion.

Controversy does exist, however, regarding the previously accepted, but never demonstrated theory that edema reduction during contrast baths occurs as a result of the "pumping mechanism" induced from the alternation of vasodilatation and vasoconstriction.^1,6 The concern that adequate deep tissue vasoconstriction fails to occur has led some rehabilitation specialists to reverse the 3:1 ratio so that cold immersion, now 3 minutes instead of 1 minute, supersedes that of the hot immersion.⁶

As a result of the potential for this heat to physiologically stimulate an increase in circulation and edema, contrast baths may serve as an appropriate treatment alternative only in the subacute, rather than acute, phase of rehabilitation.

Within the available literature, cryokinetics has been very successful in early return to preinjury activity.^1,3,5 Additional studies are needed to reinforce the efficacy of the rarely spoken art of cryokinetics. The creativity and complexity of the field of rehabilitation will flourish only when we, the artists of the profession, put forth the effort to develop and expand the talents we currently possess.

References
1. Knight KL. Cryotherapy in Sport Injury Management. Champaign, Ill: Human Kinetics; 1995:3-18, 59-71, 77, 107-130, 175-177, 217-232.
2. Barnes L. Putting injury on ice. Physicians Sportsmed. 1979;7(6):130-136.
3. Denegar CR. Therapeutic Modalities for Athletic Training. Champaign, Ill: Human Kinetics; 2000:104-111.
4. Gaydos HF, Dusek ER. Effects of localized hand cooling versus total body cooling on manual performance. J Appl Physiol. 1958;12:376-380.
5. Hayden CA. Cryokinetics in an early treatment program. Phys Ther. 1964;44:990-993.
6. Prentice WE. Therapeutic Modalities in Sports Medicine. Boston: WCB/McGraw-Hill; 1999:187-189.

Leslie J. Lear, MS, PT, ATC, CSCS, is a physical therapist with Kessler Rehabilitation and is currently working on her doctorate in sports medicine and athletic training at the University of Florida. Thomas W. Kaminski, PhD, ATC/L, is the director of the undergraduate Athletic Training Program at the University of Florida, Gainesville. They can be reached via postal mail: University of Florida, PO Box 118205, Gainesville, FL 32611-8205 or email at leslielear@yahoo.com.

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March 2002