1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 13 Cryotherapy Application for Post–Immediate Care

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Application types and times differ The key: exercise, not the cold Transition and Subacute Care Cryotherapy (cont.)

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Local Numbing with Cryotherapy Ice water immersion Ice massage Ice bag (occasionally)

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Ice Massage Slowly stroke muscle with ice pop. Discontinue when numb. Adding a plate weight will increase numbness.

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Ice Massage (cont.) Prepare ice pops by –Freezing water in 6–8 oz. paper cups –Add tongue depressor to some for handle.

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics Cryostretch Contrast bath Connective tissue stretch Transition and Subacute Care Cryotherapy: Techniques

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics Combination of cold application and active exercise

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics: Disadvantages Pain during initial session Cold can be messy.

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics: Indications Sprains—dynamite treatment –Ankle (especially) –Fingers

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics: Contraindications Any exercise or activity that causes pain Use of ice on a patient who is hypersensitive to cold

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics: Overview Typically consists of five bouts of exercise interspersed with cold application for numbing

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics Preapplication Tasks for Psychological Preparation Explain sensations. Cold very painful during first immersion. –Adapt thereafter –Benefits of treatment outweigh temporary pain.

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics Preapplication Tasks for Physical Preparation Remove clothing as necessary. Position patient.

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics Preapplication Tasks for Equipment Preparation Container and ice or ice pop Toe cap is helpful. Towels to sop up water

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics Application to Numb Body Part Apply ice. –Immersion is best. 1°C water –Use ice massage if cannot immerse.

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics Application to Numb Body Part (cont.) Toe cap or sock keeps toes warm.

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Principles of Cryokinetics Exercise: Example (cont.) Non-weight-bearing ROM –Plantar flexion –Dorsiflexion –Inversion –Eversion –Circumduction

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Weight-bearing ROM –Stand up. –Shift weight from foot to foot. –Gradually increase weight on injured limb. Principles of Cryokinetics Exercise: Example (cont.)

29. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Principles of Cryokinetics Exercise: Example (cont.) Walk 1 – Small steps – Heel to toe – Slow and deliberate No limp No pain Progress to …

30. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Principles of Cryokinetics Exercise: Example (cont.) Walk 2 Medium steps Slow and deliberate Then a little faster No limp No pain Progress to …

31. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Principles of Cryokinetics Exercise: Example (cont.) Stretch heel cords, if necessary

33. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Principles of Cryokinetics Exercise: Example (cont.) Strengthen muscles – Dorsiflexion, eversion, inversion – With Elgin ankle exerciser Progress to …

34. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Principles of Cryokinetics Exercise: Example (cont.) Jog Straight ahead Lazy S Sharp Z Work into running Progress to...

35. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Principles of Cryokinetics Exercise: Example (cont.) Four-square exercises

36. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Principles of Cryokinetics Exercise: Example (cont.) Perform individual drills – With ankle taped ½ speed ¾ speed Full speed

37. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Principles of Cryokinetics Exercise: Example (cont.) Perform team drills – With ankle taped ½ speed ¾ speed Full speed

38. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

39. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

40. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

41. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

42. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

43. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics: Maintenance Replace slush container when it cracks. Sew sides of toe caps if they rip.

44. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

45. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Rehabilitation Goals Promote healing, if tissues torn. Control pain. Reduce spasm. Control neural inhibition.

46. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Rehabilitation Goals (cont.) Reset central control through aggressive, progressive reorientation to full function. Develop muscle strength. Promote other phases of rehabilitation as explained earlier.

47. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Begin with Cryostretch Then transition into cryokinetics (for first- and second- degree injuries)

48. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryostretch: Foundation Cold application Static stretching Hold-relax technique of PNF Combination of the muscle spasm reduction techniques

49. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Ice Static stretch Isometric contraction Cryostretch: Foundation (cont.)

50. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

51. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins l Combined procedure more effective than the sum of the three individual components l Ice inexpensive; exercise free Cryostretch: Advantages

52. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins l Ice is painful to some people. –But massage not as painful as ice immersion. l Melting ice can be messy. Cryostretch: Disadvantages

53. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins l Any muscle with residual, low-grade muscle spasm l Any first-degree muscle strain l A muscle that is stiff from prolonged disuse (immobilization) –Do not confuse this with decreased ROM owing to connective tissue contractures. Cryostretch: Indications

54. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins l Any exercise or activity that causes pain l Use of ice on a person who is hypersensitive to cold Cryostretch: Contraindications

55. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Cryostretch: Precautions

56. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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) Cryostretch: Application Parameters

57. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins –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 Cryostretch: Application Parameters (cont.)

58. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Numb/renumb Isometric contraction Static stretch Cryostretch: Application Parameters (cont.) First set Second setThird set Second boutFirst bout

59. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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) Cryostretch: Application Parameters (cont.)

60. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryostretch: Application Parameters (cont.) Numb (20 min max), with ice massage

61. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Cryostretch: Application Parameters (cont.)

62. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryostretch: First Bout, First Stretch 20 sec static stretch –Stretch muscle to limit; hold 20 sec.

63. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

64. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryostretch: First Bout, Second Stretch 10 sec static stretch –Take up slack from first contraction. –Move to limits of tightness/pain. –Hold 10 sec.

65. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryostretch: First Bout, Second Contraction 5 sec isometric contraction –Instruct patient to begin and end slowly, as before.

66. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryostretch: First Bout, Third Stretch 10 sec static stretch –Take up slack from second contraction. –Move to limits of tightness/pain. –Hold 10 sec.

67. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryostretch: First Bout, Third Contraction 5 sec isometric contraction –Instruct patient to begin and end slowly, as before.

68. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryostretch: Between First and Second Bout Rest 20 sec

69. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Repeat first bout –65 sec Cryostretch: Second Bout

70. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryostretch: Second and Third Sets Renumb (5 min max) Repeat set

71. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Numb/renumb Isometric contraction Static stretch Cryostretch: Overall

72. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryostretch: Miscellaneous Tips Use shoulder if patient is too big.

73. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryostretch: Miscellaneous Tips (cont.) Stretch muscle until pain or tightness is felt, then back off until pain disappears.

74. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

75. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

76. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

77. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics: Postapplication Tasks Revisited (cont.) Schedule the next treatment. Record treatment, including unique patient responses. Clean up area.

78. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryokinetics: Maintenance Revisited Replace slush container when it cracks. Sew sides of toe caps if they rip.

79. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Combined Cryostretch and Cryokinetics Begin once spasm begins to abate. –Often within 2–3 days Replace stretching with active (isotonic) exercise.

80. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Combined Cryostretch and Cryokinetics (cont.) Begin and end with stretch. Begin cryokinetics exercises with manually resisted muscle contractions (6–10) through a full ROM.

81. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Combined Cryostretch and Cryokinetics (cont.) Once strength begins to return (2–days), switch to some type of isotonic weight lifting. Use DAPRE technique.

82. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Combined Cryostretch and Cryokinetics (cont.) Progress through all phases of rehabilitation using progressive functional activities.

83. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. The Last Word on Muscle Injury

84. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Connective Tissue Stretch Technique to break tissue contractures Used to increase joint flexibility after prolonged immobilization

85. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Connective Tissue Stretch: Foundation Combination of –Heat application –Long-term passive stretch –Cold applications

86. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Connective Tissue Stretch: Foundation (cont.) 45 min treatment

87. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

88. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

89. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Connective Tissue Stretch: Disadvantages Boring treatment

90. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Connective Tissue Stretch: Indications Anytime connective tissue contractures prevent full ROM

91. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Connective Tissue Stretch: Contraindications Any exercise or activity that causes pain Use of ice on a person who is hypersensitive to cold

92. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Connective Tissue Stretch: Precautions Avoid pain during stretching. –Usually occurs because resistance is too great

93. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Connective Tissue Stretch: Alternatives –Diathermy –Mobilization

94. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

95. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

96. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

97. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Connective Tissue Stretch: Application Parameters (cont.) Dosage –As much resistance as comfortable

98. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

99. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

100. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Connective Tissue Stretch: Postapplication Tasks (cont.) Schedule the next treatment. Record treatment, including unique patient responses. Clean up area.

101. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

102. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Lymphedema Pumps: Foundation Formerly called: –Intermittent compression pumps –Cold compression devices –Pneumatic compression pumps –Intermittent compression devices

103. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Lymphedema Pumps: Foundation (cont.) Classified as: –Pneumatic (air) –Cryocompression (chilled water) –Circumferential (all at once) –Sequential (distal to proximal)

104. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

105. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Lymphedema Pump: Advantages Requires minimal clinician time

106. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Lymphedema Pump: Disadvantages Slow rate of boot/sleeve inflation Tissue compression rate much faster with active exercise and massage.

107. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Lymphedema Pump: Indications Post-traumatic edema Postoperative edema Chronic edema Primary and secondary lymphedema Venous stasis ulcers Persistent swelling from venous insufficiency

108. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

109. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Lymphedema Pump: Precautions Avoid pain during treatment.

110. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Lymphedema Pump: Alternatives Active muscle activity Massage

111. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Lymphedema Pump: Preapplication Tasks Same as cryokinetics preapplication tasks

112. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

113. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

114. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

115. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

116. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Lymphedema Pump: Maintenance Periodically check hoses, valves, boots, and sleeves for leaks.