itis from TENS gel. Contact Dermatitis 30:305, 1994. 19. Eriksson MA, Schuller J, Sjolund BH: Letter: Hazard from transcutaneous nerve stimulation in patients with pacemakers. Lancet 1:1319, 1978. 20. Shade SK: Use of transcutaneous electrical nerve stimulation for a patient with a cardiac pacemaker: a case report. Phys Ther 65(2):206-208, 1985.
21. Sliwa JA, Marinko MS: Transcutaneous electrical nerve stimulator-induced electrocardiogram artifact: a brief report. Am J Phys Med Rehabil 75(4):307-309, 1996. 22. Philbin DM, Marieb MA, Aithal KH, et al: Inappropriate shocks delivered by an ICD as a result of sensed potentials from a transcutaneous electronic nerve stimulation unit. Pacing Clin Electrophysiol 21:2010-2011, 1998. 23. Mann CJ: Respiratory compromise: a rare complication for transcutaneous electrical nerve stimulation for angina pectoris. J Accident Emerg Med 13:68-69, 1996. 24. Glotzer TV, Gordon M, Sparta M, et al: Electromagnetic interference from a muscle stimulation device causing discharge of an implantable cardioverter defibrillator: epicardial bipolar and endocardial bipolar sensing circuits are compared. PACE 21:1996-1998, 1998. 25. Rasmussen MJ, Haves DL, Vlietstra RE, et al: Can TENS be safely used in patients with permanent cardiac pacemakers? Mayo Clin Proc 63:443, 1988. 26. Zugerman C: Dermatitis from transcutaneous electric nerve stimulation. J Am Acad Dermatol 6(5):936-939, 1982.
Also other involvement from damage to an autonomous system. No rationale provided. Note: No rationale provided.
a, For functional neuromuscular stimulation of unbraced, short distance ambulation in traumatic paraplegia; b, Morbid obesity; c, Rationale for CI is need for good cardiovascular status because the eﬀort (O2 testing) to stand and ambulate during FNS is 6 times normal.
Note: No rationale provided.
Patient may be unreliable or manipulative in program. The candidate must desire an increased level of independence. The MMPI is an antisocial-sociopathic index.
a, Functional electrical stimulation as active physical therapy. He uses medical criteria (MC) to minimize risk during FES.
a, Intact lower motor neuron; b, Spasticity needs to be controlled.
C4/5 is the upper limit needed to allow diaphragmatic drive (C3-4-5) for aerobic activities.
a, May be CI.
Also, consult dermatology if chronic skin diseases.
Tightness will limit standing and walking. The contractures need to be corrected.6 Unclear if FES programs may lead to a Charcot joint.
Joint ossiﬁcation. SCI patients with severe osteoporosis (due to disuse) are predisposed to fractures.5 Spinal deformity compromises standing ability and may require too much eﬀort from the UEs for stability.
a, Severe; b, Severe scoliosis; c, Irreversible contracture.
Also, consult with urologist if chronic renal disease.
High-grade sores require surgery ﬁrst.
Support is needed because individuals generally require assistance to don the devices. Monitor cardiac and vitals signs during FES program.
Also, monitor level of consciousness (i.e., visual acuity), fatigue, diaphoresis, grip. Inquire “How do you feel?” Ashley2 reported autonomic dysreﬂexic blood pressure responses in 10 individuals with high SCI during 30-minute FES-assisted leg extension exercises used to improve cardiovascular ﬁtness. Upon stimulation, systolic BP immediately increased. In two persons, SBP >200 mm Hg. The authors caution SCI above T6 during FES exercise. In a proposed mechanism, ES is perceived as noxious below the level of the lesion, causing massive sympathetic response, vasoconstriction, and hypertension.
Terminate exercise beyond these levels: Systolic BP not >180 mm Hg and not 120 mm Hg and not 160 bpm and not 2 hours; 4 had to be rescued while swimming). Symptoms included urticaria wheals primarily on the face, neck, and hands. One patient had dysphagia after drinking cold water/ice cream.
The athlete was diagnosed with peroneal nerve palsy. Six months later, atrophy of the right extensor digitorum brevis occurred; other muscles were slightly weak and sensation improved. At 7 months, he started (noncontact) football practices. Symptoms were reproduced by immersing hands in water at 8° C for 6 minutes: Local responses included pallor, redness, and swelling. Latent, systemic response, after 3-6 minutes, included a ﬂushed face, a sharp fall in BP, a rise in pulse rate, and a tendency toward syncope. Transitory recovery occurred after 10 to 15 minutes.
Authors caution against cryotherapy with compression, and to check patient every 5 to 10 minutes for distal signs of paresthesia or numbness. The authors recommended desensitization as a treatment for hypersensitivity to cold.
The wound tensile strength of albino rabbits was evaluated under lower environmental temperatures. A 22-year-old football player presented with soreness of the left ankle (tender anterior taloﬁbular ligament) and left distal hamstring.
The environmental temperature was lowered from 20° C to 12° C.
Tensile strength of wounds decreased 20% after 5 days of temperature reduction.
The athlete self-administered, with the athletic trainer’s recommendation, an ice pack over bare skin on the left ankle and rested for 20 minutes. The posterior distal left thigh rested over the ice pack.
A 42-year-old woman with idiopathic Raynaud’s phenomenon.
She was applying hair spray color to her child’s costume, using the right index ﬁnger to depress the spray button.
Upon removal of the ice, the individual was unable to move the left foot (no sensory warning). Shortly afterward, minimal movement was possible. The following week, the foot moved against gravity and numbness was noted over the anterior lateral leg region. A 2/5 grade of dorsiﬂexion, eversion, great toe extension were noted. The athlete was diagnosed with a common peroneal nerve injury proximal to ﬁbular head with axonotmesis due to cryotherapy. A 0.5-cm, yellow indurated, depressed, macule developed. She was diagnosed with a localized necrosis of her ﬁngertip. Laboratory measures indicated the product could get cold enough to cause vasospasms.
The authors believe reﬂex vasoconstriction of skin was a primary factor in the impaired healing. Motor and sensory impairment were recovered 12 months following injury. The author cautions against cryotherapy treatments in patients with low body fat or in nerve areas not protected by subcutaneous tissue.
She healed without scarring within 2 weeks. The author suggests caution about cold injuries with some aerosol products in these patients.
A 59-year-old woman strained her calf muscle at gym while running. Staﬀ provided an ice pack and instructed the client to apply it.
A 15-year-old high school football player sustained a nonspeciﬁed injury that resulted in joint eﬀusion.
A 79-year-old man dropped a suitcase on his left great toe.
The woman applied the ice pack directly to the site without intervening material for 20 minutes while resting the calf over the pack. The athlete was instructed to keep the ice pack on for the duration of the practice session (2 hours).
A large blistered area formed over a 24-hour period. She was diagnosed with a superﬁcial partial-thickness burn requiring treatment of the blister and dressing. Upon removal of the ice, anesthesia was noted over the anterior lateral tibial muscles and left dorsal foot area. There was weakness in dorsiﬂexion, and an inability to extend the great toe. The athlete was diagnosed with superﬁcial and deep peroneal nerve palsy.
He self-administered ice packs unremittingly for 3 days. His toes were blistered, discolored, warm, “weeping,” and had delayed reﬁlling times.
The burn healed in 10 days.
He was treated with a foot drop brace and 10 days of electrical stimulation to the anterior lateral tibial musculature. After about 30 days, complete recovery of function and sensation occurred. The trainer subsequently modiﬁed the ice protocol by placing an iced elastic bandage between the ice and athlete’s skin. Ice packs should be used episodically, not continually.
A 35-year-old man with right epididymitis was told to apply ice as part of treatment.
He self-administered synthetic frozen gel pack to the area.
tetanus toxoid/immune globulin, and antibiotics. 10 days later, redness and erosion over the scrotum was noted. Prolonged direct contact of the cold pack with skin (improper) led to a diagnosis of superﬁcial frostbite.
Warm soaks and topical steroid cream led to healing. The authors caution to wrap ice packs in towels; do not apply directly to the skin.
 The neck of the bottle broke oﬀ ; the contents escaped and hit the woman in the face and one eye.
She claimed the eye became red and blistered. She