One common sequela of stroke is difficulty performing movements due to spasticity or increased muscle tone. More severe cases of spasticity may result in limited functional independence of daily activities such as ADLs of eating, bathing, toileting, dressing, bathing, and grooming (ADLs).
Spasticity has been defined differently, but one common definition is marked by an increase in speed-dependent movement associated with an exacerbation of deep reflexes caused by hyperexcitability of the stretch reflex. Aside from common joints such as the shoulder, elbow, and digits, the wrist may often be spastic and flexed. One finding for occupational therapy may be an increase in spasticity in the Modified Ashworth Scale. Another may be low functional independence scores such as in the FIM or Modified Barthel Index for ADLs.
Cryotherapy is a technique that can be used for the treatment of spasticity to reduce tension and promote neuromuscular function. Ice works by reducing the activity of the muscle spindle and causing a decreased afferent stimulation. Effects of ice application include lowering of tone and abnormal patterns to allow for strengthening, range of motion, coordination, and functional activities. Furthermore, the beneficial effects from ice application can last for a considerable amount of time, from 30 minutes to 2 hours.1
In a study by Cruz and colleagues (2019) 2 , ice was applied as a modality for the treatment of wrist spasticity in patients with hemiparesis after a stroke. Forty patients with mean age 60.5 in the cryotherapy group saw an increase in palmar grip strength after treatment with maintenance a month after completion.
- Patients remained seated with forearm resting on a table and elbow flexed to 90 degrees.
- Cryotherapy was applied for 25 minutes to the wrist flexors using a plastic bag containing ice and a wet towel wrapped around it.
- Patients underwent two 30-second sets of passive stretching of wrist flexors and extensors.
- Patients performed three sets of 15 wrist flexion and wrist extension.
According to the researchers, cryotherapy promoted an increase in the patient’s palmar grip strength (p=0.0244) and was maintained for a month after treatment. While the exact mechanisms behind how and why cryotherapy are effective for improving muscle strength remain unclear, it has been suggested that it may be related to changes in the impulse propagation of the neurons due to the influence of temperature. It is worth noting that cooling alone may not be enough to promote the desired effects for this population. In this study, the authors noted that because the cryotherapy effects are only temporary, it is also important to pair this modality with exercises — stretches and active assisted movement. This can be seen as a preparatory activity before the actual therapy.
For occupational therapy, it may be a good opportunity after this protocol to encourage the patient to perform meaningful and functional activities for the patient. This could be ADLs, IADLs, leisure, etc. Examples of activities to practice that involve the upper extremity along with gripping include:
- Holding a toothbrush to brush teeth
- Holding a comb and mirror to brush hair
- Holding supplies to apply make-up
- Holding a towel to wash your face
- Holding a bar of soap or sponge for bathing
- Holding to toilet paper for hygiene
- Holding a cell phone to take a picture
- Holding a cup to get a drink of water
- Holding utensils for eating
- Felice TD, Santana LR. Recursos Fisioterapêuticos (Crioterapia e Termoterapia) na espasticidade: revisão de literature. Revista Neurociências. 2009; 17(1):57-62.↑
- Cruz, A. T., Januário, P. D. O., Paula, A. R. D., Lima, F. P. S., & Lima, M. O. (2019). Effects of cryotherapy associated with kinesiotherapy and electrical stimulation on spastic hemiparetic patients. Fisioterapia e Pesquisa, 26, 185-189.↑