Article

Does Cryotherapy Hasten Return to Participation? A Systematic Review

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Abstract

OBJECTIVE: To search the English-language literature for original research addressing the effect of cryotherapy on return to participation after injury. DATA SOURCES: We searched MEDLINE, the Physiotherapy Evidence Database, SPORT Discus, the Cochrane Reviews database, and CINAHL from 1976 to 2003 to identify randomized clinical trials of cryotherapy. Key words used were cryotherapy, return to participation, cold treatment, ice, injury, sport, edema, and pain. DATA SYNTHESIS: Original research, including outcomes-assessment measures of return to participation of injured subjects, was reviewed using the Physiotherapy Evidence Database (PEDro) Scale. Four studies were identified and reviewed by a panel of certified athletic trainers. The 4 articles' scores ranged from 2 to 4 on the PEDro scale, which has a maximum of 10 points. Two of the articles suggested that cryotherapy speeds return to participation after ankle sprains. However, these authors failed to provide in-depth statistical analysis of their results. A confounding factor of compression as part of the treatment prevented interpretation of the effects of cryotherapy in 1 article. CONCLUSIONS: After critically reviewing the literature for the effect of cryotherapy on return-to-participation measures, we conclude that cryotherapy may have a positive effect. Despite the extensive use of cryotherapy in the management of acute injury, few authors have actually examined the effect of cryotherapy alone on return-to-participation measures. The relatively poor quality of the studies reviewed is of concern. Randomized, controlled clinical studies of the effect of cryotherapy on acute injury and return to participation are needed to better elucidate the treatment responses.

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... RICE therapy (rest, ice, compression, elevation) has been a universally accepted clinical practice for immediate treatment of any soft tissue injury including sprains, strains and contusions (4,5,9). In recent years, new protocols with strong evidence supporting early mobilisation, education, and avoiding anti-inflammatory drugs have been encouraged. ...
... The use of ice for muscle damage or acute soft tissue injuries has been shown to reduce pain (4), however, despite this, it is generally agreed that there is a lack of well controlled studies investigating its true efficacy and optimal mode, duration and frequency of use (5, 6; 8). There is some evidence that icing may enhance the speed at which athletes return to training and competition (5,9). There is some evidence that cold water immersion attenuates acute anabolic signalling and long-term adaptations in muscle to strength training (33). ...
... There is some evidence that cold water immersion attenuates acute anabolic signalling and long-term adaptations in muscle to strength training (33). Therefore, there needs to be an awareness of the impact of icing on recovery from soft tissue injuries (5,33). Alternatively, icing to treat soft tissue injuries may reduce the size of hematomas (10) and ultimately provide an optimal environment from which tissue healing and regeneration can be initiated. ...
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ABSTRACT Whilst individual components of the RICE (rest, ice, compression, elevation) principle have been tested, limited research has been conducted to prove the efficacy of this treatment modality in its entirety. To determine the efficacy of RICE therapy in ameliorating indices of muscle damage, and to investigate the 'repeated bout' phenomenon-which refers to how the adaptation to a single bout of eccentric exercise protects against muscle damage from subsequent eccentric exercise bouts, and if this is adaptation is observed following RICE intervention. Untrained males (n=16, age= 20y ± 1.3, height=1.8m ± 0.7, weight= 78.35kg) performed two bouts of eccentrically biased exercise, 4 weeks apart. After determining the participants' one rep max (1RM), the exercise bout, consisting of 4 sets of eccentric bicep curls at varying percentages of the participants 1RM, was performed. After bout 1, participants were assigned to a group receiving either RICE therapy or a non-medicated cream. Creatine kinase was 50% lower (p<0.05) for RICE during the 24h post-exercise intervals. Isometric strength was ~7% higher (p<0.0001) for RICE, suggesting less strength loss. Muscle soreness during movement was ~5% lower (p=0.009) for RICE. RICE experienced ~4% less (p=0.05) reduction in range of motion. Indirect measures of muscle damage (except for strength within the first 12h) were significantly lower after bout 2 for both groups. Results suggest that RICE therapy reduces markers of exercise-induced muscle damage. In addition, the typical adaptation seen after one bout of eccentrics is still present following RICE therapy.
... Intermittent or continuous cryotherapy with ice packs, gel packs or Hilotherm face mask reduces the skin temperature causing reduced tissue metabolism, vasoconstriction and lessens the excitability of peripheral nerve fibers, which is assumed to diminish the inflammatory response following SRM3 [6][7][8][9] . However, the therapeutic efficacy of cryotherapy following SRM3 has previously been assessed in systematic review and meta-analyses with conflicting results [10,11] . ...
... Pain is considered the worst sequelae following SRM3 and usually most pronounced the first day [12,13] . Visual analogue scale (VAS), self-administrated question-naire, numeric or verbal rating scaleand consumption of analgesics are the most commonly used methods of pain assessment revealing improved therapeutic efficacy of intermittent and continuous cryotherapy on pain, as documented in recent published systematic reviews and meta-analyses [10,14,15] . ...
... Pain is generally considered the worst nuisance following SRM3 causing mild to severe physical discomfort and commonly interfere with a person's quality of life and general functioning [12,13] . The therapeutic efficacy of cryotherapy on pain relief following SRM3 has previously been assessed in systematic reviews concluding negligible effect of short-term continuous cryotherapy, which is in accordance with the results of the present study [10,11,29] . However, a significant reduction in pain has been reported with continuous cryotherapy for 45 minutes or intermittent cryotherapy for 30 minutes every hour during the 24 hours or every hour and a half during 48 hours [16,17,30] . ...
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Purpose: The aim was to test the null-hypothesis of no difference in pain, trismus, swelling and quality of life following surgical removal of mandibular third molar (SRM3) with 30 minutes of immediate cryotherapy compared with no cryotherapy using clinical assessment, visual analogue scale (VAS), questionnaires and three-dimensional imaging. Methods: Thirty-one patients (14 men and 17 female) were randomly allocated to cryotherapy (test) or no cryotherapy (control) in a split-mouth study design. Preoperative measurements included VAS score of pain, maximum mouth opening , delineation of facial morphology using three-dimensional imaging and oral health impact profile-14. Pain, trismus, swelling and quality of life were assessed after one day, three days, seven days and one month, respectively. Swelling was analysed using superimposition of three-dimensional facial surfaces andtemplate matching technique. Descriptive and generalised estimating equation analyses were made. Level of significance was 0.05. Results: Thirty minutes of immediate cryotherapy following SRM3 revealed no statistically significant differences in pain, trismus, swelling or quality of life compared with no cryotherapy. Females disclosed significant less pain after one month compared with males (P< 0.05). Trismus was significantly associated with increased length of surgery (P< 0.05). Conclusion: The therapeutic efficiency of cryotherapy following SRM3 seems to be negligible. However, further randomised controlled trials assessing longer use of cryotherapy or intermittent application are needed before definite conclusions can be provided about the beneficial use of cryotherapy following SRM3.
... There are several studies that suggest the cyclical application of ice is beneficial with the pain management of soft tissue injuries (3,8,16,19,26). Kellett (19) suggests "cryotherapy for 10 to 20 minutes, two to four times per day for the first two to three days is helpful in promoting early return to activity." MacAuley (26) and Bleakley (3) had similar findings. ...
... The authors of these studies have merely supported the notion that ice therapy may be beneficial in pain management, but not one could definitively prove that ice decreased swelling or attenuated the recovery process. In some cases, the authors suggested that 6/19 evidence in support of icing is insufficient and more studies are warranted (8,16,47). There is no evidence in the available literature that definitively supports the notion that ice belongs in a rehabilitation protocol for an acute musculoskeletal injury, unless pain reduction is the only desired outcome. ...
... In addition, the application of ice, or cryotherapy, has been found to not only delay recovery, but to also damage tissue in the process (9,20,27,49). The evidence suggests that the application of ice is only necessary if pain reduction is the desired outcome (3,8,16,19,26). Evidence in support of compression and elevation is lacking, as most studies are inconclusive (4,35,51) and fail to establish definitive application guidelines that are supported by research. These findings, along with the public recant from Dr. Gabe Mirkin in 2015 (31), support the premise that the RICE protocol, which is a generally preferred method of immediate treatment for acute musculoskeletal injuries, is a myth. ...
Article
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The RICE (Rest, Ice, Compression, Elevation) protocol has been the preferred method of treatment for acute musculoskeletal injuries since its origin in a 1978 publication entitled "Sports Medicine Book" by Dr. Gabe Mirkin. These guidelines have been used by coaches and healthcare providers for over four decades with the intent of expediting the recovery process and reducing inflammation. Although popular, the implementation of this protocol to attenuate the recovery process is unsubstantiated. There is, however, an abundance of research that collectively supports the notion that ice and rest does not enhance the recovery process, but instead delays recovery, and may result in further damage to the tissue. Research in regard to compression and elevation is inconclusive, diluted and largely anecdotal. Definitive guidelines for their application have yet to be purported. As a result of the subsequent research that examined the validity of the protocol, Dr. Mirkin recanted his original position on the protocol in 2015. The objective of this article is to analyze the available evidence within the research literature to elucidate why the RICE protocol is not a credible method for enhancing the recovery process of acute musculoskeletal injuries. In addition, evidence-based alternatives to the protocol will be 1/19 examined. These findings are important to consider and should be utilized by any healthcare professional; specifically, those who specialize in the facilitation of optimal recovery, as well as those who teach in health-related disciplines in higher education.
... 3 Cryotherapy, in its turn, consists in the use of ice in a therapeutic character for reducing metabolic activity, blood flow, edema, and for promoting pain relief. [4][5][6][7][8] Surface electromyography (EMG) has been widely used in clinical applications and research in several areas of interest, including physiotherapy. It is used as an important method of noninvasive neuromuscular assessment in different scientific areas such as sports sciences, neurophysiology and rehabilitation. ...
... 17 We emphasize that the higher the frequency, the greater the absorption of the ultrasound waves [24][25][26][27] and that, for the therapeutic ultrasound to produce the desired thermal effect, it is necessary to heat the tissue up to 40 to 45°C for at least 5 minutes. 6,[28][29][30]31 In this context, Gallo et al. 32 described the increase of 2.8° + 0.8°C in the gastrocnemius muscle (3 MHz, 1.0 W / cm 2 , for 10 minutes), was not enough cause thermal effect. In this study we did not observe any changes in the parameters of strength. ...
... Continuous ultrasound heat generation and its application as a thermotherapeutic resource has been questioned, since it can suffer the interference of many factors, including the amount of protein and fat of the treated tissue 6,20,21,31 and there is no technique that limits ultrasound absorption to a single specific type of tissue. 34 Several authors argue that collagen-rich tissues (fascia, tendons, ligaments) are the ones that better absorb the ultrasound radiation. ...
Article
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A alteração na temperatura de um tecido pode promover efeitos fisiológicos que levam a alterações circulatórias e nervosas, tais como vasodilatação e aumento na flexibilidade. Objetivo: Avaliar, através de uma avaliação neuromuscular não invasiva, como a termoterapia influencia na força muscular e nos sinais mioelétricos do bíceps braquial em contração isométrica. Métodos: Dezessete voluntários foram orientados a fazer contração isométrica do músculo bíceps braquial concomitantemente com a eletromiografia de superfície. A avaliação eletromiográfica e de força foram realizadas antes e após a intervenção com recursos termoterapêuticos: gelo (15 minutos) e ultrassom continuo (1MHz, 0.8W/cm2, 7 minutos). Resultados: Mostraram que as mulheres possuem menos força e ativam menos unidades motoras. No entanto, a frequência de disparos elétricos nas vias efetoras é maior, o que indica maior propensão à fadiga. Após a aplicação do calor, não foram observadas diferenças na resposta neuromuscular do bíceps braquial em contração. Já a crioterapia, promoveu redução significativa na força e no número de unidades motoras ativadas durante a contração. O resfriamento do tecido muscular promove a diminuição da ação das fibras musculares, uma vez que há redução da velocidade da condução do impulso nervoso e do reflexo do arco miotático. Além disso, a crioterapia também diminui a sensibilidade dos órgãos tendinosos de Golgi, aumenta a viscosidade sanguínea, provoca a vasoconstrição. Todos estes fatores, somam-se para culminar na diminuição da ativação neuromuscular e, consequentemente, na redução da força do músculo.
... The time chosen for the application based on the physiological principle of cold. (20) In both groups, the VAS was applied at the beginning, at the end and at each interval of the technique application. Patients have adopted a position of comfort during the application of the protocol and they were not oriented to remain in any position. ...
... The cold depresses the excitability of free nerve endings and peripheral nerve fibers which are responsible for the pain threshold, the decrease of the inflammatory mediator release which induce pain is one of the ice effects. (20,24) The analgesia may be perceived seven to ten minutes of application, in most patients, and the effect of cold on the driving speed may last up to 30 minutes after application. (20,24) Therefore, it is possible to be said that the first CRYO application that principle was demonstrated, since significant pain reduction was observed. ...
... (20,24) The analgesia may be perceived seven to ten minutes of application, in most patients, and the effect of cold on the driving speed may last up to 30 minutes after application. (20,24) Therefore, it is possible to be said that the first CRYO application that principle was demonstrated, since significant pain reduction was observed. ...
Article
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Background: The delivery pain is an unpleasant experience which may generate some insecurity for the woman. Thus, some methods of analgesia need to be studied in order to generate greater comfort for the woman during labor. Objective: to evaluate the effect of transcutaneous electrical nerve stimulation (TENS) and cryotherapy (CRYO) on labor pain. Method/Design: quasi experimental study, randomized sample in two groups: TENS and CRYO. Pregnant women were selected in the Carmela Dutra Maternity (Florianópolis (SC), Brazil) according to inclusion criteria: women which are pregnant for the first time, age (18-40 years) and initial cervical dilatation of 4-5cm. The Visual Analogue Scale (VAS) was used to evaluate pain before and after each intervention. Results: 24 parturient women were studied (TENS = 11, CRYO = 13). In the TENS group, there was a significant result in pain relief after the first application (p = 0.002). VAS was reduced from 8 to 5.5, but not significant. In the CRYO group there was reduction of pain during the first application (p = 0.008), and in the second there was an increase in pain (p = 0.008). There was a significant difference between the techniques in the evaluation performed before the second application, with a lower value attributed to the CRYO group (p = 0.034). Conclusions: CRYO and TENS were effective in relieving pain during the first phase of the initial phase of labor. However, during the treatment, in the parturient women studied, there was maintenance of pain response by the CRYO group and decrease in the TENS group without reduction significant.
... 3 Por sua vez, a crioterapia consiste na utilização de gelo em caráter terapêutico e tem como objetivo reduzir a atividade metabólica, o fluxo sanguíneo, o edema, além de promover alivio de dor. [4][5][6][7][8] A eletromiografia (EMG) de superfície tem sido muito utilizada em aplicações clínicas e em pesquisas de diversas áreas de interesse, incluindo a fisioterapia, sendo utilizada como um importante método de avaliação neuromuscular não invasivo, tendo destaque em vários campos distintos como ciências do esporte, neurofisiologia e reabilitação. 9 Propriedades anatômicas e fisiológicas do tecido muscular, bem como a aplicação de recursos terapêuticos, podem interferir no controle do sistema nervoso periférico e, consequentemente, no sinal eletromiográfico. ...
... No entanto, sabe-se que o aumento de 2° C no tecido corresponde a um aumento de 20% na velocidade de contração do tecido muscular.17 Cabe destacar que, quanto maior a frequência, maior será a absorção das ondas de ultrassom 24-27 e que, para que o US terapêutico produza o efeito térmico desejado, é necessário que o tecido seja aquecido a 40-45° C por, no mínimo, 5 minutos.6,[28][29][30]31 Neste sentido, Gallo et al.32 descreveram o aumento de Tabela 4. Teste de correlação de Pearson para os parâmetros clínicos e de força e eletromiografia do membro dominante Os dados de idade corporal, gordura visceral e corporal e músculo esquelético foram obtidos por bioimpedância. ...
Article
Full-text available
A alteração na temperatura de um tecido pode promover efeitos fisiológicos que levam a alterações circulatórias e nervosas, tais como vasodilatação e aumento na flexibilidade. Objetivo: Avaliar, através de uma avaliação neuromuscular não invasiva, como a termoterapia influencia na força muscular e nos sinais mioelétricos do bíceps braquial em contração isométrica. Métodos: Dezessete voluntários foram orientados a fazer contração isométrica do músculo bíceps braquial concomitantemente com a eletromiografia de superfície. A avaliação eletromiográfica e de força foram realizadas antes e após a intervenção com recursos termoterapêuticos: gelo (15 minutos) e ultrassom continuo (1MHz, 0.8W/cm2, 7 minutos). Resultados: Mostraram que as mulheres possuem menos força e ativam menos unidades motoras. No entanto, a frequência de disparos elétricos nas vias efetoras é maior, o que indica maior propensão à fadiga. Após a aplicação do calor, não foram observadas diferenças na resposta neuromuscular do bíceps braquial em contração. Já a crioterapia, promoveu redução significativa na força e no número de unidades motoras ativadas durante a contração. O resfriamento do tecido muscular promove a diminuição da ação das fibras musculares, uma vez que há redução da velocidade da condução do impulso nervoso e do reflexo do arco miotático. Além disso, a crioterapia também diminui a sensibilidade dos órgãos tendinosos de Golgi, aumenta a viscosidade sanguínea, provoca a vasoconstrição. Todos estes fatores, somam-se para culminar na diminuição da ativação neuromuscular e, consequentemente, na redução da força do músculo.
... Two of the reviews investigated early dynamic training. 9,21 The remaining 3 articles explored bracing versus functional treatment, 7 cryotherapy, 22 and exercise and manual therapy. 23 A critically appraised topic was included containing 3 studies exploring deep oscillation therapy in athletes with acute LAS. ...
... Moreover, none of the included systematic reviews had a sole focus on athletes RTS; instead, athletes were combined with the general population in all analyses. 7,9,[21][22][23] Most sports require movement patterns that involve a combination of forces in multiple directions whilst maintaining the need for optimal technique. 41 Given the increased multidirectional forces associated with sports when compared with a typical walking pattern, the increased demands of an athletic population when developing a rehabilitation program should be considered. ...
Article
Context: Acute lateral ankle sprain (LAS) is a common injury in athletes and is often associated with decreased athletic performance and, if treated poorly, can result in chronic ankle issues, such as instability. Physical performance demands, such as cutting, hopping, and landing, involved with certain sport participation suggests that the rehabilitation needs of an athlete after LAS may differ from those of the general population. Objective: To review the literature to determine the most effective rehabilitation interventions reported for athletes returning to sport after acute LAS. Evidence acquisition: Data Sources: Databases PubMed, Embase, CINAHL, SPORTDiscus, and PEDro were searched to July 2020. Study selection: A scoping review protocol was developed and followed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews guidelines and registered (https://osf.io/bgek3/). Study selection included published articles on rehabilitation for ankle sprain in an athletic population. Data extraction: Parameters included athlete and sport type, age, sex, intervention investigated, outcome measures, measurement tool, and follow-up period. Data synthesis: A qualitative synthesis for all articles was undertaken, and a quantitative subanalysis of randomized controlled trials and critical methodological appraisal was also conducted. Evidence synthesis: A total of 37 articles were included in this review consisting of 5 systematic and 20 narrative reviews, 7 randomized controlled trials, a single-case series, case report, position statement, critically appraised topic, and descriptive study. Randomized controlled trial interventions included early dynamic training, electrotherapy, and hydrotherapy. Conclusions: Early dynamic training after acute LAS in athletes results in a shorter time to return to sport, increased functional performance, and decreased self-reported reinjury. The results of this scoping review support an early functional and dynamic rehabilitation approach when compared to passive interventions for athletes returning to sport after LAS. Despite existing research on rehabilitation of LAS in the general population, a lack of evidence exists related to athletes seeking to return to sport.
... For many years, whole body cryotherapy has been used as an efficient form of treatment of rheumatological and degenerative disorders, injuries, burns, muscle spasticity and bone disorders [10]. Positive changes observed in the organism after whole body cryotherapy introduction encouraged its use as a biological regeneration procedure in sports [11,12,13]. In her work, Chwalbińska-Moneta [14] presented the results obtained in rowers, in whom the use of whole body cryotherapy resulted in an improvement in the circulatory and metabolic tolerance to physical exercise, the increasing fatigue during muscle engagement slowed down, while stress reactions to the progressive fatigue during muscle engagement slowed down. ...
... If the decision making process is efficient, the player quickly and adequately analyses the situation and knows how to properly select the information received during a match, while the effectiveness of the athlete's actions is high and increases the probability of scoring a point. Knowing that the course of cognitive processes is of key importance in sports regardless of discipline [2,23,26], while whole body cryotherapy has been administered as a tool of medical support for athletes for many years [11,12,27], the aim of this study was to verify a potential novel correlation between these two phenomena. No observations have been made, that would confirm the effect of changing the cognitive functions in high-ranked athletes as a result of physical training combined with whole body cryotherapy. ...
Article
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Introduction. Using the Quick Mind Testing method, the efficiency of cognitive functions in kayakers after physical training combined with whole body cryotherapy was assessed. Material and methods. The athletes (n = 17) performed the Quick Mind Testing on the first day and at the end of a 2-month training cycle, as well as before and after whole body cryotherapy conducted between the 5th and the 15th day of the cycle. Cryotherapy was administered twice a day, before and after training (20 sessions altogether). One cryotherapy session lasted 3 mins with the temperature gradually decreased from the initial -120oC to the final -145oC. Results. After the training period, the kayakers committed approx. 2 times less incorrect Go and NoGo reactions, and approx. 12% more correct NoGo (p < .004) reactions, as well as gave more correct answers in the ATTENTION test (p < .004) than on the first day of training. After cryotherapy, as compared with the results obtained before the cryochamber stimulation, the kayakers gave more correct answers in the ATTENTION test. Conclusions. Physical training combined with whole body cryotherapy increases the mental efficiency of kayakers, which may affect the efficiency of physical exercise.
... When available, cold-water immersion is preferred due to cooling efficiency (13,15,21) and the ability to treat peripheral edema through hydrostatic pressure (3). The use of cryotherapy on an acute musculoskeletal injury may result in a faster return to play and a reduced risk of secondary hypoxic injury (12). Although a quick return to play is desirable, the goal of acute injury International Journal of Exercise Science http://www.intjexersci.com ...
... However, as highlighted in previous reviews, there is no randomised controlled trial (RCT) investigating cryotherapy in the treatment of acute soft tissue injuries. [17][18][19] Indeed, only one article examining the effects of cryotherapy on human muscle injury was eligible in the current review; a pilot study examining the feasibility of an RCT on cryotherapy to treat gastrocnemius tears. 20 The small sample size of this study did not demonstrate a difference between the cryotherapy and the control condition on pain perception, functional capacity recovery and convalescence time. ...
Article
Sports medicine physicians and physiotherapists commonly use cryotherapy (eg, ice application) postinjury to decrease tissue temperature with the objective of reducing pain, limiting secondary injury and inflammation, and supporting healing. However, besides the analgesic effect of cryotherapy, a literature search revealed no evidence from human studies that cryotherapy limits secondary injury or has positive effects on tissue regeneration. Thus, our current understanding of the potential mechanisms and applications of cryotherapy largely relies on the results from animal studies. Importantly, treatment should not aim at obliterating the inflammatory and regeneration processes but instead aim to restore an adapted/normal regulation of these processes to improve function and recovery. However, some animal studies suggest that cryotherapy may delay or impair tissue regeneration. With the translation of laboratory animal studies to human sport medicine being limited by different injury and muscle characteristics, the effect of cryotherapy in patients with musculoskeletal injuries is uncertain. Thus, pending the results of human studies, cryotherapy may be recommended in the first 6 hours following an injury to reduce pain (and possibly haematoma), but it should be used with caution beyond 12 hours postinjury as animal studies suggest it may interfere with tissue healing and regeneration.
... In sports physiotherapy, techniques such as applying heated packs, heating comforters, or utilising tepid showers are frequently employed to alleviate chronic pain, prepare athletes for training, and reduce muscle tension. Additionally, in order to increase range of motion and decrease the risk of injury, thermal therapy is frequently applied prior to stretching and exercise (Hubbard TJ, 2004). ...
Chapter
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The COVID-19 epidemic boosted the implementation of telemedicine in sports rehabilitation. Wearable technology and smartphone applications make it possible for athletes to receive instruction and treatment remotely and track their development. In order to keep patients interested and motivated throughout physical therapy, virtual reality (VR) and exergaming platforms are employed. They may boost motivation and commitment to recovery regimens. Platelet-rich plasma (PRP), stem cell therapy, and other regenerative therapies are being researched for their potential in expediting tissue regeneration and decreasing downtime for sports. Advancements in neurorehabilitation are being used to sports rehab, helping athletes recover from brain injuries more efficiently and safely. Helping athletes get back on their feet by catering to their unique dietary requirements throughout the healing process. Integration of biometric data for providing athletes with appropriate strength and conditioning is also discussed in this chapter. With the use of biometric data from wearable devices and sensors, rehabilitation programs may be fine-tuned in real-time based on the patient's immediate needs. Custom orthotic devices and rehabilitation gear are made for each athlete using 3D printing and other modern manufacturing processes. There is a larger focus on utilizing scientific data to drive rehabilitation regimens, ensuring that therapies are effective and safe.
... Cryotherapy use in musculoskeletal injuries has been widely debated [68,69]. Purported benefits include pain control and reduced inflammation, but little high-quality evidence exists to support these claims [68,[70][71][72]. Cryotherapy may blunt the inflammatory response after PRP by decreasing platelet activation, infiltration of inflammatory cells, and expression of proangiogenic factors [65,68,69]. ...
Article
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Purpose of Review The field of orthobiologics has developed markedly over the past decade, particularly with respect to the applications of platelet-rich plasma (PRP) in chronic musculoskeletal injuries. This review will cover the current understanding of PRP and focus on the post-procedure rehabilitation phase to augment outcomes in hip pathologies. Recent Findings Numerous level 1 studies support the role of PRP as a superior treatment for several chronic musculoskeletal conditions such as knee osteoarthritis, lateral epicondylopathy, gluteus medius tendinopathy, etc. Additionally, the optimal components and refinement methods of PRP with relation to tendinopathy versus osteoarthritis are currently under investigation. However, the literature is scant on optimal rehabilitation protocols after these procedures. Summary Physical rehabilitation is critical for the recovery of musculoskeletal injuries, especially when considering the goal of long-term functional improvement. Although PRP is a promising treatment modality for enhancing the healing process of chronic musculoskeletal injuries, quality exercise/rehabilitation at the appropriate timing after procedure is likely to accelerate the recovery process and augment PRP outcomes.
... Furthermore, there is no evidence that isolated application of ice can reduce pain and swelling, as well as improve function in people with an acute ankle sprain [23][24][25]. Cryotherapy is commonly used to treat pain, swelling, and bleeding caused by vasoconstriction [23,24,26]. Although there is insufficient evidence, the use of PRICE therapy in the acute setting for short-term pain relief to expedite early mobilization is a reasonable, routine, and safe method [17]. ...
... Ice decreases pain and presumably reduces swelling after an ankle sprain. 35 There is a controversy among researchers about the preferred cryotherapy protocol, with some recommending application for 20 to 30 minutes and others advising for 10 minutes and repeating the application at least 3 to 4 times per day during the first 5 days of treatment. 36 ...
Article
Key Points: Ankle sprains show gender differences, with female competitors being 25% more likely to sustain such injuries compared with male competitors. Despite the high frequency of ankle sprains, the ideal management is controversial, and a significant percentage of patients sustaining an ankle sprain never fully recover. Studies show that around 70% of patients experiencing a first-time ankle sprain will recur in the future or may develop chronic ankle instability. The acronym POLICE (protection, rest, optimal loading, ice, compression, and elevation) can summarize the management of acute ankle sprains. A rehabilitation-based conservative program is the mainstream for lateral ankle sprain treatment but surgery can be considered in high-level athletes.
... Previously published systematic reviews conclude that there is a need for more sufficiently powered, high-quality studies of humans with homogeneous injuries. In the studies, cryotherapy should be the sole intervention that is investigated in order to reach more conclusive results to create a basis for evidence-based recommendations (Adie et al., 2012;Bleakley et al., 2004;Brosseau et al., 2003;Hubbard et al., 2004;Raynor et al., 2005;van den Bekerom et al., 2012). ...
... A study by Lowitzsch et al. (1977) found that applying cold application to the skin and causing its temperature to drop to 27°C led to a change in the nerve conduction velocity. When the skin temperature drops to 10-15°C, cell metabolism slows, and the antiinflammatory effect is augmented (Greenstein, 2007;Hubbard et al., 2004;Mac Auley, 2001;Sapega et al., 1988). If the skin temperature drops to 13.6°C or the cold application lasts 20 min, an analgesic effect can then be achieved (Bugaj, 1975;Greenstein, 2007;Lee et al., 1978). ...
Article
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Aim and objectives: To conduct a systematic review and meta-analysis to evaluate the effects of cold application on pain and anxiety reduction after chest tube removal (CTR). Background: The act of removing the chest tube often causes pain among cardiothoracic surgery patients. Most guidelines regarding CTR do not mention pain management. The effects of cold application on reducing pain and anxiety after CTR are inconsistent. Design: Systematic review and meta-analysis. Methods: We searched six databases, including Embase, Ovid Medline, Cochrane Library, Scopus, the Index to Taiwan Periodical Literature System and Airiti Library, to identify relevant articles up to the end of February 2021. We limited the language to English and Chinese and the design to randomised controlled trials (RCTs). All studies were reviewed by two independent investigators. The Cochrane Collaboration's tool was used to assess the risk of bias, Review Manager 5.4 was used to conduct the meta-analysis. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology was used for assessing certainty of evidence (CoE). Results: Ten RCTs with 683 participants were included in the meta-analysis. The use of cold application could effectively reduce pain and anxiety after CTR. The subgroup showed that a skin temperature drops to 13°C of cold application was significantly more effective for the immediate reduction in pain intensity after CTR compared with control group. The GRADE methodology demonstrated that CoE was very low level. Conclusion: Cold application is a safe and easy-to-administer nonpharmacological method with immediate and persistent effects on pain and anxiety relief after CTR. Skin temperature drops to 13°C or lasts 20 min of cold application were more effective for immediate reduction of pain intensity following CTR. Relevance to clinical practice: In addition to pharmacological strategy, cold application could be used as evidence for reducing pain intensity and anxiety level after CTR.
... 14,15 Studies have shown that cryotherapy has an overall positive effect on injured athletes returning to play. 16 Cryotherapy includes the use of topical cooling methods such as ice packs, ice towels, ice massages, and gel packs, as well as wholebody cryotherapy (WBC) methods including cold watereice immersion (CWI) and newer commercial WBC devices that work by using cold air currents. A recent systematic review by Jinnah et al. 17 reported statistically significant findings in terms of decreased subjective muscle soreness and pain levels in athletes who used CWI in comparison to passive recovery. ...
Article
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The increase in female participation in athletics over the past decade has been accompanied by an increase in injury rates as a result of higher demands placed on athletes. Although previous studies have shown that anatomic, biomechanical, hormonal, and psychological factors may play a role in differences between men and women that can influence injury risk in athletes, there is still a lack of understanding of sex-related mechanisms of injury, guidelines, and prevention strategies. This article provides an overview of common injuries affecting female athletes. We present guidelines for upper- and lower-extremity injury rehabilitation, focusing on considerations specific to the female athlete with the goal to facilitate a safe return to sports. Level of Evidence Level V, expert opinion.
... Within the first 24 hours postoperatively, the pain reaches highest intensity and gradually resolves after seven days [16,17]. Previous published systematic reviews have reported negligible effect of short-term continuous cryotherapy, which is in accordance with the results of the present study [18][19][20]. Consequently, continuous short-term cryotherapy seems not to diminish postoperative sequelae following SRM3. ...
Article
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Objectives: Cryotherapy is frequently used to diminish postoperative sequelae following mandibular third molar surgery. The objective of this single-blinded randomized controlled trial was to assess the therapeutic efficiency of 30 minutes continuous cryotherapy on postoperative sequelae following surgical removal of mandibular third molars compared with no cryotherapy. Material and Methods: Thirty patients (14 male and 16 female) including 60 mandibular third molars were randomly allocated to 30 minutes of immediately cryotherapy or no cryotherapy. Outcome measures included pain (visual analogue scale score), maximum mouth opening (trismus) and quality of life (oral health impact profile-14). Outcome measures were assessed preoperatively and one day, three days, seven days and one month following surgical removal of mandibular third molars. Descriptive and generalized estimating equation analyses were made. Level of significance was 0.05. Results: No cryotherapy following surgical removal of mandibular third molars revealed a statistically significant lower visual analogue scale score of pain compared to thirty minutes of continuous cryotherapy after one day (P < 0.05). However, no statistically significant difference in trismus or oral health-related quality of life were revealed at any time point compared with no cryotherapy. Conclusions: The therapeutic effect of 30 minutes continuous cryotherapy following surgical removal of mandibular third molars seem to be negligible. Thus, further randomized controlled trials assessing a prolonged application period of cryotherapy, alternative devices or use of intermittent cryotherapy are needed before definite conclusions and evidence-based clinical recommendations can be provided.
... A study by Lowitzsch et al. [28] found that applying cold application to the skin and causing its temperature to drop to 27°C led to a change in the nerve conduction velocity. When the skin temperature drops to 10°C-15°C, cell metabolism slows, and the anti-in ammatory effect is augmented [27,[29][30][31]. If the skin temperature drops to 13.6°C or the cold application lasts 20 minutes, an analgesic effect can then be achieved [12,27,32]. ...
Preprint
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Background and Objective: Data on the effects of cold application on reducing pain and anxiety after chest tube removal (CTR) are inconsistent. This study aimed to conduct a systematic review and meta-analysis to evaluate the effects of cold application on pain and anxiety reduction after CTR. Methods: We searched six databases, including Embase, Ovid Medline, Cochrane Library, Scopus, the Index to Taiwan Periodical Literature System, and Airiti Library, to identify relevant articles up to the end of February 2021. We limited the language to English and Chinese and the design to randomized controlled trials (RCTs). All studies were reviewed by two independent investigators. The Cochrane Collaboration’s tool was used to assess the risk of bias, and Review Manager 5.4 was used to conduct the meta-analysis. Results: Ten RCTs with 623 participants were included in the meta-analysis. The use of cold application could effectively reduce immediate pain and had persistent effects on pain after CTR. There were significant effects of cold application on reducing anxiety. The meta-regression showed that a drop in skin temperature to the 13°C target of cold application was significantly more effective for the immediate reduction in pain intensity compared with receiving up to 20 minutes target of cold application. Conclusion: Cold application is a safe and easy-to-administer nonpharmacological method with immediate and persistent effects on pain and anxiety relief after CTR. In particular, skin temperature drops to the 13°C target of cold application were effective for immediate reduction of pain intensity following CTR.
... Previously published systematic reviews conclude that there is a need for more sufficiently powered, high-quality studies of humans with homogeneous injuries. In the studies, cryotherapy should be the sole intervention that is investigated in order to reach more conclusive results to create a basis for evidence-based recommendations (Adie et al., 2012;Bleakley et al., 2004;Brosseau et al., 2003;Hubbard et al., 2004;Raynor et al., 2005;van den Bekerom et al., 2012). ...
Article
Purpose This review aimed to evaluate the certainty of evidence for the use of cryotherapy in patients with musculoskeletal disorders. Methods PubMed, Embase, Cochrane Library and AMED were searched from January 2000 to January 2018 (update June 2019) for systematic reviews (SRs) and randomized controlled trials (RCTs) reporting outcomes on pain, swelling, range of motion (ROM), function, blood loss, analgesic use, patient satisfaction and adverse advents. The papers were categorised into: after surgical procedures, acute pain or injury and long-term pain or dysfunction. Methodological quality and risk of bias were assessed using the AMSTAR and the Swedish Health Technology Assessment instruments. Level of certainty of evidence was synthesized using GRADE. Study selection Eight SRs and 50 RCTs from a total of 6027 (+ 839) were included. In total 34 studies evaluated cryotherapy in surgical procedures, twelve evaluated cryotherapy use in acute pain or injury and twelve studies evaluated cryotherapy in long-term pain and dysfunction. Results The certainty of evidence is moderate (GRADE III) after surgical procedures to reduce pain, improve ROM, for patient satisfaction and few adverse events are reported. Cryotherapy in acute pain and injury or long-term pain and dysfunction show positive effects but have a higher number of outcomes with low certainty of evidence (GRADE II) Conclusion Cryotherapy may safely be used in musculoskeletal injuries and dysfunctions. It is well tolerated by patients. More advanced forms of cryotherapy may accentuate the effect. Future research is needed where timing, temperature for cooling, dose (time) and frequency are evaluated.
... The historical consensus has been that ice decreases pain, inflammation, and edema, while heat can facilitate movement in rehabilitation by improving blood flow and decreasing stiffness. [1][2][3] In our practice, we encourage use of both topical modalities as a way to start exercise therapy when pain from the acute injury limits participation. Patients often ask which modality they should use. ...
... 4 Cryotherapy is a therapeutic strategy widely used for the treatment of muscle injuries, 5,6 as it has anti-inflammatory and antioxidant actions, resulting from the attenuation of microvascular dysfunction after injury, the promotion of analgesia, vasoconstriction, edema reduction, hemorrhage control, decreased nerve conduction speed, and tissue perfusion. 7,8 Thus, cryotherapy is considered to be an important strategy for preventing damage to adjacent tissues caused by excessive leukocyte infiltration or enzymatic or hypoxic mechanisms, 9 and by the production of reactive oxygen species (ROS), 10 therefore constituting a means of attenuating damage caused by the exacerbation of inflammatory processes. A common method of delivering cryotherapy is the application of three doses daily (for 20 min each) 11 using packs of crushed ice 12,13,14 applied directly onto the skin. ...
Article
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Cryotherapy is a therapeutic modality widely used for the treatment of muscle injuries to control pain and inflammatory processes. This study aimed to investigate the effects of cryotherapy on the inflammatory and oxidative stress parameters and mechanical properties of, and pain in, the skeletal muscles of rats with lacerative muscle injury. The rats were anesthetized with 4% isoflurane and subjected to gastrocnemius muscle laceration injury. After injury, all animals in the intervention groups received cryotherapy treatment for 20 minutes using plastic bags containing crushed ice. The protocol comprised three daily applications at 3-hour intervals on the day of injury, with reapplication 24 hours later. Seventy-two male Wistar rats were divided into three groups: sham, muscle injury (MI), and MI + cryotherapy (MI + cryo). Muscle mechanical properties were analyzed by mechanical tensile testing on day 7 after injury. The MI + cryo group showed reduced TNF-α, IFN-γ, and IL1β levels; elevated IL4, IL6, and IL10 levels; reduced oxidant production and carbonyl levels; and elevated sulfhydryl contents. Animals that underwent tissue cooling showed superoxide dismutase activity and glutathione levels close to those of the animals in the sham group. The MI and MI + cryo groups showed reduced values of the evaluated mechanical properties and lower mechanical thresholds compared to those of the animals from the sham group. Our results demonstrated that the proposed cryotherapy protocol reduced the inflammatory process and controlled oxidative stress but did not reverse the changes in the mechanical properties of muscle tissues or provide analgesic effects within the time frame analyzed.
... There is a positive effect of cryotherapy in the acute injury on return to participation measurement 9 . Heat and contrast bath plus simultaneous exercise is not effective than the ice submersion with simultaneous exercise at reducing swelling. ...
... Cryotherapy is routinely used for the management of acute musculoskeletal injuries and swelling after orthopaedic interventions. 14,15 Reduced temperature of the skin and subcutaneous tissue causes vasoconstriction, decreases the excitability of peripheral nerve fibres and lessens the metabolic rate, which diminish the inflammatory response. 18,19 Cryotherapy can be applied as a continuous treatment modality (applied for a set length of time and then removed) or intermittent (applied for shorter amounts of time, but is reapplied several times over the treatment course). ...
Article
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The objective was to test the hypothesis of no difference in facial swelling, pain, trismus and immediate quality of life after surgical removal of mandibular third molars, with or without postoperative cryotherapy. A MEDLINE (PubMed), Embase database and Cochrane library search in combination with a hand search of relevant journals was conducted by including human randomized controlled trials published in English until the 17th of July 2018. The search identified 37 titles. Six studies with low or unclear risk of bias fulfilled the inclusion criteria. Intermittent cryotherapy for 30 minutes during the first postoperative days significantly diminished facial swelling, pain and trismus compared with no cryotherapy. Patient's satisfaction and perception of recovery was significantly increased with cryotherapy. Therapeutic efficacy of intermittent cryotherapy on postoperative facial swelling, pain and trismus seems to be improved compared with continuous cryotherapy. Considerable variations in study design, diversity of used evaluation methods, outcome measures as well as various methodological confounding factors posed serious restrictions to review the literature in a quantitative systematic manner. Thus, conclusions drawn from the results of this systematic review should be interpreted with caution. Further well‐designed randomized controlled trials including standardized protocol, larger patient sample, blinded outcome assessors, patient‐reported outcome measures and three‐dimensional volumetric analysis of facial swelling are required before evidence based recommendations can be provided. This article is protected by copyright. All rights reserved.
... Segundo a literatura, a crioterapia pode ser aplicada em qualquer situação na qual o controle da dor aguda ou crônica, a redução do espasmo e da espasticidade muscular se façam necessários [7][8][9][10]. Porém, sua maior aplicabilidade é vista nos estágios infl amatórios agudos e subagudos decorrentes de traumas músculo-esqueléticos [11,12] e no pós-operatório imediato [13,2]. Razões para isto vão desde questões históricas [1,14] aos efeitos fi siológicos que ocorrem em resposta à queda da temperatura dos tecidos [2]. ...
Article
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Crioterapia, ou terapia com frio, é um método muito utilizado em traumas músculo-esqueléticos, pós-operatório, dor miofascial, espasmo muscular, espasticidade e condições inflamatórias. Diversas técnicas de crioterapia são aplicadas, entretanto, seu uso é realizado de forma indiscriminada. Apesar da maioria dos trabalhos na literatura apontar efeitos satisfatórios do uso do frio, ainda existem controvérsias em relação à real eficácia desse recurso, principalmente relacionadas à inflamação e ao edema. Este estudo teve como objetivo buscar fundamentações científicas que possam ajudar a esclarecer o papel da crioterapia no edema traumático, a fim de que o profissional de reabilitação possa utilizar essa modalidade com melhor embasamento científico. Para a realização deste trabalho, foi feita uma pesquisa documental de artigos científicos em revistas, jornais e sites, além de um levantamento bibliográfico em livros relacionados ao temaem questão. Existemevidências dos efeitos positivos da crioterapia no controle do edema. Entretanto, determinados trabalhos apontaram efeitos insatisfatórios. Vale a pena salientar que as disparidades observadas nesses estudos se devem ao fato de que, muitas vezes, a aplicação da crioterapia é feita de forma inadequada, gerando assim, conclusões precipitadas. Com base nesta revisão bibliográfica, sugere-se que a crioterapia é um recurso eficaz quando aplicado imediatamente ao trauma.Palavras-chave: lesão, inflamação, edema, crioterapia.
... What is also important, an early detection of proprioception deficit and implementation of an appropriate exercise/rehabilitation program can prevent functional instability of a joint and consequently its repetitive injury (Hewett et al., 2006;Laskowski et al., 2000;Lephart et al., 1998). Such exercise programs frequently involve the use of cryotherapy (Hubbard et al., 2004;Swenson et al., 1996). Although, application of cryotherapy is relatively straightforward, much controversy and confusion remain regarding the understanding of how cryotherapy influences proprioception. ...
Article
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The proprioceptive information received from mechanoreceptors is potentially responsible for controlling the joint position and force differentiation. However, it is unknown whether cryotherapy influences this complex mechanism. Previously reported results are not universally conclusive and sometimes even contradictory. The main objective of this study was to investigate the impact of local cryotherapy on knee joint position sense (JPS) and force production sense (FPS). The study group consisted of 55 healthy participants (age: 21 ± 2 years, body height: 171.2 ± 9 cm, body mass: 63.3 ± 12 kg, BMI: 21.5 ± 2.6). Local cooling was achieved with the use of gel-packs cooled to -2 ± 2.5°C and applied simultaneously over the knee joint and the quadriceps femoris muscle for 20 minutes. JPS and FPS were evaluated using the Biodex System 4 Pro apparatus. Repeated measures analysis of variance (ANOVA) did not show any statistically significant changes of the JPS and FPS under application of cryotherapy for all analyzed variables: the JPS’s absolute error (p = 0.976), its relative error (p = 0.295), and its variable error (p = 0.489); the FPS’s absolute error (p = 0.688), its relative error (p = 0.193), and its variable error (p = 0.123). The results indicate that local cooling does not affect proprioceptive acuity of the healthy knee joint. They also suggest that local limited cooling before physical activity at low velocity did not present health or injury risk in this particular study group.
... Although cryotherapy is commonly prescribed after soft tissue injuries, the evidence-supporting cold therapy is limited. There is some clinical evidence that cryotherapy may be effective for pain following an acute musculoskeletal injury, but systematic reviews consistently note the lack of quality clinical studies [100][101][102]. In regenerative procedures, one concern is that cryotherapy may decrease platelet activation [92]. ...
Article
Aim: Significant variability exists in the literature, with no clear consensus to the optimal protocol after a regenerative procedure. Given this uncertainty, the authors systematically reviewed the literature cataloging the different variables that may influence outcomes. Methods: Search was limited to randomized clinical trials and prospective cohort studies of regenerative procedures for the treatment of tendinopathy. Variables were predetermined, and included: cyrotherapy, pre- and post-procedure nonsteroidal anti-inflammatory drugs use, recommendations for alternative pain medications, immobilization and duration of rest. Variables were categorized based on the influence of the intervention on the three phases of healing. Results: 749 studies were assessed for eligibility, and 60 studies were included. Significant variability existed in the literature. Conclusion: Despite the importance of rehabilitation after regenerative procedures, there is a paucity of evidence available to guide clinicians and highlights the need for additional validation.
... Multiple systematic reviews, however, found that the existing scientific evidence is insufficient to conclude whether this modality is actually effective in improving clinical outcomes such as reduced pain and swelling, improved function, and quicker return to participation in normal activity following acute soft tissue injury [3,[5][6][7][8][9]. For example, a recent systematic review of 10 randomized controlled trials with a meta-analysis investigated the effectiveness of cryotherapy following anterior cruciate ligament reconstruction (ACL-R) on various outcomes, including pain, edema, and knee function [9]. ...
Article
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PURPOSE To summarize evidence regarding efficacy of focal joint cooling on muscle function. METHODS Literature review was performed to determine effectiveness of focal joint cooling on muscle function. Therapeutic cooling, professionally termed cryotherapy, has a long history in sports medicine because it has been widely used for a variety of therapeutic purposes. However, it has been contraindicated in rehabilitation for patients with muscle dysfunction because it is believed that cryotherapy has detrimental effects on muscle function. It is clinically important to recognize that the negative outcomes may result from the common mode of cryotherapy involving the direct cooling of muscle fibers. In contrast, there is promising evidence that when cryotherapy targets joints where muscle fibers are not located, the negative effects on muscle function can be eliminated or there can even be positive effects on muscle function. RESULTS Focal joint cooling appears to be effective in increasing motor neuron activation in patients with joint pathology in the lower extremity, leading to greater muscle strength. In addition, joint cryotherapy may be capable of negating deficiencies in functional performance while it was not found to be neither beneficial nor harmful to reflexive action and postural control. CONCLUSIONS Joint cryotherapy can be a safe and effective intervention for improving muscle function, and it should be indicated for patients with persistent muscle dysfunction.
... Whereas Hubbard and the co-authors stated that cryotherapy procedures have a positive influence on the duration of coming back to work or to sports activity in people. They observed that the physical therapy procedures, that were applied, influenced the therapeutic rehabilitation process of the injured soft tissues [15]. Taradaj and the co -authors think that cryotheraphy should be applied in case of acute joint and soft tissue injuries [7]. ...
Article
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Objective: Sports training of the horse requires from the animal a high level of strength and weight endurance. Therefore sport training carries a considerable risk of the appearance of overload changes and injury occurrence, especially in muscular and skeletal systems. Soft tissue lesions (of tendons, ligaments and muscles) are a very frequent type of an injury in sports horses. Study Design: The study is aimed at presenting the original project of physiotherapeutic measures including complex therapy methods, applicable after the injury of rupture of tendon fibers of the accessory head of the deep digital flexor muscle. Animal: Horse. Material and Methods: The therapeutic program was employed in a sports horse. The therapy lasted five weeks. Applied treatments: the Cito instant cold compress, kinesio taping - a lymphatic application, kinesio taping with the ligament technique, cryotherapy, deep transverse friction massage, ultraphonophoresis and restoring soft tissues elasticity and joint mobility. Results: All of the offered physiotherapeutic procedures turned out to be effective in treating. Conclusion: The complex application of therapeutic procedures offer allows the horse to come back to participation in show jump competitions.
... We observed that a clinically utilized dose of cryotherapy does not have a substantial impact on the transcriptome or metabolome of healthy muscle tissue. This largely agrees with epidemiological studies and meta-analyses which have failed to demonstrate a positive impact of cryotherapy on the treatment of skeletal muscle injuries 9,10 . Given the high rates of skeletal muscle injuries in the physically active population, further work which explores the effect of cryotherapy on the cellular and molecular processes that regulate muscle repair after injury in humans is necessary to further refine the therapeutic use of cold in the sports medicine setting. ...
Article
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Cryotherapy is commonly used in the treatment of skeletal muscle injuries. However, the data to support the use of cryotherapy is inconclusive, and the biochemical etiology of cryotherapy in human skeletal muscle remains largely unknown. We therefore sought to determine how a clinically-relevant dose of cryotherapy would impact the transcriptome and metabolome of skeletal muscle. Eight healthy male subjects (age 24.7 ± 4.5 years, BMI 22.2 ± 1.6) received a 15 minute bout of local cryotherapy, delivered via ice cup massage over the anterolateral thigh. This resulted in an 85% decrease in skin temperature and a predicted 27% reduction in intramuscular temperature. The contralateral side served as a non-treated control. Two hours after cryotherapy, muscle biopsies were obtained to analyze changes in the transcriptome, metabolome, and activation of p38 MAPK, ERK1/2, Akt, and p70S6K proteins. No changes were detected in the transcriptome between control and cooled muscles. Cryotherapy reduced levels of hexose sugars and hypoxanthine by 1.3%, but no statistically different changes were observed in 60 additional metabolites. Overall, no differences in phosphorylated p38 MAPK, ERK1/2, Akt, and p70S6K were observed. A clinically relevant dose of cryotherapy produced negligible acute biochemical and molecular changes in the skeletal muscle of human subjects.
... Nevertheless, the effectiveness of cryotherapy applications can only be measured through optimal performance of athletes after such treatment [16 -18]. Regardless of the method applied, systematically reviewed literatures found that cryotherapy benefits athletes after both local and whole body therapy [4,15,[19][20][21]. ...
Article
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The use of cryotherapy in injury management (IM) has been widely studied but report on track and field athletes' (TFAs) perception in Ghana remains scarce. TFAs in Ashanti region of Ghana habitually sustained acute injuries due to competition stressors that typically affect peak performance like in other contact games. Despite been observed that sustained injuries accomplished cryotherapy treatment, TFAs' visit to non-clinical therapy nonetheless remain prominent. This cross-sectional study therefore documents the perceptions of TFAs on the use cryotherapy in IM. Ninety five [mean age = 22.26±1.10years, 59 (62.1%) males, 36(37.9%) females] TFAs camped at the Babayara Sports stadium Kumasi in preparation for 11 th African Games were purposively sampled. Self-structured and validated instrument on the use of cryotherapy in IM was administered to elicit TFAs perceptions. TFAs perceived the use of cryotherapy in IM as significant [F = 788.884, X 2 = 404.192, df = 94, p = .000].-216 Gender influence on TFAs perception of use of cryotherapy in IM was not significantly different. Mainstream significantly professed at least a good feeling (79.0%, X 2 = 37.000, p = 000) after receiving cryotherapy treatment. As such, attachement of Physical Therapists to the TFAs training sessions in Ashanti region, provision of enabling environment and equipment to enhance effective IM processes through cryotherapy are strategic approaches advocated.
... While these in vitro and in vivo animal model studies have been somewhat informative, and would generally be predicted to reduce muscle regeneration and impair force production, often times the dose and extent of the cryotherapy or thermal ultrasound is much greater than what is used clinically, making it a challenge to directly apply these findings to patients. There have been some descriptive epidemiological studies that have looked at cryotherapy and thermal ultrasound in patients with muscle injuries, but these studies have produced conflicting results on the efficacy of these modalities in improving patient outcomes 48,49,53,[60][61][62] . Further animal studies using more clinically relevant temperature changes and larger epidemiological studies in patients with muscle strain injuries, could further enhance the evidence-based application of these modalities in the sports medicine setting. ...
Article
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Eccentric contraction-induced skeletal muscle injuries, can be included in what is clinically referred to as muscle strains, are among the most common injuries treated in the sports medicine setting. Although patients with mild injuries often fully recover to their pre-injury levels, patients who suffer moderate or severe injuries can have a persistent weakness and loss of function that is refractory to rehabilitation exercises and currently available therapeutic interventions. The objectives of this review are to describe the fundamental biophysics of force transmission in muscle and the mechanism of muscle strain injuries, as well as the cellular and molecular processes that underlie the repair and regeneration of injured muscle tissue. The review will also summarize how commonly used therapeutic modalities affect muscle regeneration, and opportunities to further improve our treatment of skeletal muscle strain injuries.
... The role of cold water immersion in accelerating post-effort recovery has been questioned [4]. The restoration of normal physiological parameters from exercise-related variables, and maintaining or improving the functionality of the assessed body region indicates an adequate recovery. ...
Article
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Objective: The purpose of this study was to determine the effect of cold water immersion on the vertical jump and the Subjective Feeling of Perceived Exertion (SFPE). Design: A test-retest design with two-hour interval. Setting: University Campus. Participants: Seventeen physical education female students (mean±SD 21.29±4.52 yr, 163.61±6.02 cm, 56.29±6.68 kg) volunteered for this study. Methods: All subjects performed a series of functional tests: Squat Jump (SJ), Countermovement Jump (CMJ), sprint 30m, and jogging (CC) 1000m, with registration of the subjective Rating of Perceived Exertion (sRPE) by Borg scale (Borg, 1970) at the end of the last test (Time 1, M1). The experimental group was treated with cold water immersion in a tank of ice water (13ºC) for 5 minutes while the control group reposed sitting. The experiment was repeated two hours later (Time 2, M2). Comparisons were made using a one-tailed, independent-samples t-test. Results: Both flight time (p=.003) and height (p<.001) SJ test showed significantly higher in the experimental group. CMJ test findings were also significantly higher in this group compared to flight time (p=.001) and height (p<.001). The experimental group also offered superior figures in terms of sRPE, although the differences were not statistically significant (p=0.475). Conclusion: Cold water immersion exerts a beneficial effect on vertical jump ability and allows a better and greater recovery of this capacity. Future research should help identify optimal parameters for cold therapy and its possible influence on different physical qualities.
... Rehabilitation and sport medicine specialists have proposed using cryotherapy during muscle regeneration to minimize muscle injury [11][12][13][14], since a greater quantity of injured tissue requires a longer recovery time [5]. Many studies, although not all [15], have highlighted that cryotherapy may be beneficial to recovery, as it reduces inflammation within the affected muscles [16][17][18][19][20]. ...
Article
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Objectives: To investigate the effects of multiple cryotherapy applications after muscle injury on markers of oxidative stress. Methods: Following cryolesion-induced skeletal muscle injury in rats, ice was applied at the injured site for 30 minutes, three times per day, on the day of injury, and for 2 days after injury. To determine the effect of the cryotherapy treatment on markers of oxidative stress, biochemical analyses were performed 3, 7, and 14 days after injury. Results: Compared with non-treated animals, cryotherapy reduced dichlorofluorescein at 7 and 14 days post-injury and thiobarbituric acid reactive substances levels at 3 and 7 days post-injury (P < 0.05). Additionally, cryotherapy maintained methyl thiazol tetrazolium reduction levels compared to the control group at all analyzed time points (P > 0.05), whereas non-treated groups demonstrated lower levels than the control group (P < 0.05). Superoxide dismutase activity at 7 and 14 days post-injury and catalase activity at 3 days post-injury were lower in cryotherapy groups compared with non-treated groups (P < 0.05). Cryotherapy prevented the reduction of non-protein thiol levels and maintained within control group level, at 3 days post-injury (P = 0.92). Discussion: Cryotherapy reduced the production of reactive oxygen species after muscle injury, resulting in an attenuated response of the antioxidant system. These findings suggest that using multiple cryotherapy applications is efficient to reduce oxidative stress.
... Further, the applied whole-body cryotherapy may have elicited additional systematic changes, like core temperature reduction and cardiovascular or endocrine changes potentially responsible for the outcome. According to two previously published reviews there is some evidence to suggest that cryotherapy may hasten the return to participation 36 and decreases the pain that is associated with soft tissue injury 37 . Nevertheless, both reviews concluded that the quality of available trials in that field of research is poor and that high-quality studies are needed to provide evidence based guidelines for the application of cryotherapy. ...
Article
Background: Recovery from exercise and competition is important in sports medicine, particularly when rest periods are short. The objective is to determine the efficacy of cryo exposition (CRY) and manual lymphatic drainage (MLD) to hasten short term recovery of muscle performance after eccentric contractions. Methods: In a randomized controlled trial, 30 healthy sport students (21 males, 9 females; age: 25.7±2.8 years) performed 4×20 eccentric contractions of knee extensors, followed by 30 min MLD, CRY, or rest (RST) under controlled laboratory environment. Maximal voluntary contractions (MVC), electrically induced muscle fatigue (FI), and electrically induced tetani (EIT) at low (T2: 20 Hz) and high frequencies were tested. Results: Force decline and recovery kinetics regarding MVC, FI, and EIT did not differ significantly (p<0.05) between groups. That is, 24 h after the intervention, MVC (MLD: 80.9±5.5%; CRY: 81.1±8.5%; RST: 83.5±7.3%), FI (MLD: 83.2±23.7%; CRY: 81.2±38.8%; RST: 93.2±22.9%), and EIT (T1: MLD: 53.0±29.5%; CRY: 39.0±32.9%; RST: 46.3±26.1%; T2: MLD: 84.2±27.2%; CRY: 64.2±24.2%; RST: 66.6±22.3%) were similarly depressed irrespective of applied treatments. Conclusion: Neither CRY nor MLD hastened the recovery of muscle performance, when applied for 30 min. Identification number of the Primary Registry Network: DRKS00007608.
Chapter
This chapter discusses basic principles that appear to be useful in the treatment and rehabilitation of musculoskeletal injuries. It provides some specific advice for reducing the risk of developing musculoskeletal disorders in the occupational setting. The chapter describes procedures that may help reduce the pain and promote the healing process when an injury does occur. It then focuses on some of the lifestyle habits that have been shown to be of benefit to musculoskeletal health. Dietary factors appear to be important with respect to musculoskeletal health. Obesity is a risk factor for musculoskeletal disorders in general. There are many ways in which cumulative damage may accrue. The cumulative damage development might be the result of a mono‐task job, or more often, jobs comprised of multiple tasks. Adoption of non‐neutral postures may have an important role in increasing stress on musculoskeletal tissues, which has an important impact on the fatigue life of tissues.
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Introduction:Musculoskeletal rehabilitation is one of the frontline domains in physical therapy practice. In most countries, physical therapists prefer independent practice with referrals from general practitioners and orthopedic surgeons. Under these circumstances, the physical therapist may be the first contact professional handling these individuals who may not have adequate medical records with their personal medical history. Cryotherapy for pain relief could be the first choice of pain management opted by a musculoskeletal therapist. That is when both the therapist and the patient have to be aware of the undesirable effects of cryotherapy application and its potential local and systemic complications. The outcome of this paper could be an initiative for a standardized screening process to be incorporated into physical therapy practice. Clinical Findings:A 30-year-old man with left knee pain who underwent exercise therapy in the physiotherapy unit of a tertiary care center developed erythematous rashes around the knee following ice application. It was noted that the patient was not aware of the same in the past. The patient was attended by a dermatologist, and a diagnosis of cold urticaria was made following confirmation with cold stimulation test. Conclusion:From this study, it may be concluded that the awareness of cold-induced urticaria has to be emphasized on both patients and health care professionals. A simple screening protocol should be made mandatory in orthopedic physical therapy practice, which would suffice this purpose. Keywords: Urticaria, cryotherapy, Physical therapy
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Acute ankle sprain is the most common lower limb injury in athletes and accounts for 16%-40% of all sports-related injuries. It is especially common in basketball, American football, and soccer. The majority of sprains affect the lateral ligaments, particularly the anterior talofibular ligament. Despite its high prevalence, a high proportion of patients experience persistent residual symptoms and injury recurrence. A detailed history and proper physical examination are diagnostic cornerstones. Imaging is not indicated for the majority of ankle sprain cases and should be requested according to the Ottawa ankle rules. Several interventions have been recommended in the management of acute ankle sprains including rest, ice, compression, and elevation, analgesic and anti-inflammatory medications, bracing and immobilization, early weight-bearing and walking aids, foot orthoses, manual therapy, exercise therapy, electrophysical modalities and surgery (only in selected refractory cases). Among these interventions, exercise and bracing have been recommended with a higher level of evidence and should be incorporated in the rehabilitation process. An exercise program should be comprehensive and progressive including the range of motion, stretching, strengthening, neuromuscular, proprioceptive, and sport-specific exercises. Decision-making regarding return to the sport in athletes may be challenging and a sports physician should determine this based on the self-reported variables, manual tests for stability, and functional performance testing. There are some common myths and mistakes in the management of ankle sprains, which all clinicians should be aware of and avoid. These include excessive imaging, unwarranted non-weight-bearing, unjustified immobilization, delay in functional movements, and inadequate rehabilitation. The application of an evidence-based algorithmic approach considering the individual characteristics is helpful and should be recommended.
Article
Cryotherapy has demonstrated its efficacy in post-traumatic soft tissue pain, through its anti-inflammatory action. Its postoperative use has also been the topic of many studies and has now proved its efficacy in indications such as ligament or knee arthroplasty surgery. The aim of this study was to analyze the effect of cryotherapy on pain and analgesic consumption after wrist or base of the thumb surgery. We prospectively included 60 patients from March 2017 to May 2018. All these patients had undergone wrist or base of the thumb surgery involving a bone procedure. Thirty patients were managed with cryotherapy (the Handfreez® splint), 30 patients were included in the control group with conventional immobilization. The data collected included a visual analogue scale (VAS), and analgesic and non-steroidal anti-inflammatory drug (NSAID) consumption, both during the hospital stay and then at home for one week. The results from the two groups were compared. During the hospital stay, morphine consumption was significantly lower in the cryotherapy group (p = 0.04). At home, NSAID consumption was significantly lower in the cryotherapy group (p = 0.009). The VAS score was not significantly different between the two groups. In our study, we demonstrated the benefits of cryotherapy on consumption of analgesics and NSAIDs after bone surgery of the wrist or the base of the thumb.
Thesis
Background: The theory and practice of knowledge translation underpins evidence-based practice (EBP). There is significant concern that translation of research-based evidence into clinical practice is slow and incomplete. This thesis investigates evidence for this concern in the case of a common injury, (which is managed by a variety of clinicians) the acute lateral ankle ligament sprain (LALS), and a tool frequently used to enhance EBP, the clinical practice guideline (CPG). The aim of this research is to sequentially investigate the pathway for transmission of evidence contained in CPGs through curriculum, student knowledge, and physiotherapy practice to the experience of the final consumer (the patient) using LALS as the case study. Methods: Initially, a systematic review of LALS CPGs was conducted. CPGs were critically appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument online version, My AGREE PLUS. A qualitative study of educators involved in teaching LALS curricula for the Australasian College of Sports and Exercise Physicians, St John Ambulance first aid, pharmacy, nursing, and physiotherapy was performed using thematic analysis. Three online surveys completed the five studies. A survey of students to determine what they learn about LALS, a survey of clinicians to investigate their clinical practice in relation to LALS and, a survey of patients who have had a LALS to determine what treatment they received. The components of management found in the studies were compared with the most recent 2018 CPG for LALS. Results: This study found that generally, CPGs for physiotherapists (USA and Netherlands), athletic trainers (USA), physicians (Netherlands and USA) and nurses (USA, Canada, and Australia) are of poor quality. Educators, physiotherapy students, and physiotherapists prefer textbooks to CPGs to inform EBP. Across the five groups investigated, there was no common curriculum. As they practiced only triage management, the nurses, pharmacists and first aid trainers had little concept of the importance of severity of injury. In contrast, the physician and physiotherapy educators establish severity to guide management. The physicians and physiotherapists derive their judgement from their own research and reflective EBP. Australian physiotherapists and physiotherapy students are generally following the recommendations from the 2018 LALS CPG; specifically, medication advice, functional support, optimal loading, rest, ice, compression, elevation, exercises, and manual therapy and are not using electrophysical agents for LALS. Physiotherapists and physiotherapy students may be compromising safety by advising nonsteroidal anti-inflammatory drugs (NSAIDs), despite there being no curriculum that teaches them about drug interactions and the effects of these medications in delayed healing. This may be a scope of practice problem and requires further research. Four hundred and thirty-two patients with LALS completed the survey. LALS patients reported that they received recommendations from their treating physiotherapist; specifically, ice, compression, ultrasound, exercises, protection (crutches) and manual therapy. Conclusions LALS CPGs are of poor quality. Generally educators, physiotherapy students and physiotherapists do not use them to inform EBP and prefer text books. Possibly, LALS patients may not be receiving optimal EBP. Further research is needed to determine why CPGs are not used and which interventions may be useful in enhancement of knowledge transfer thereby improving patient outcomes. Key Terms: Clinical Practice Guidelines, Evidence-based Practice, manual Therapy, Physical Therapy/Rehabilitation, Physical Therapy Modalities, NSAIDs
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Background: Acute lateral ankle ligament sprains (LALS) are a common injury seen by many different clinicians. Knowledge translation advocates that clinicians use Clinical Practice Guidelines (CPGs) to aid clinical decision making and apply evidence-based treatment. The quality and consistency of recommendations from these CPGs are currently unknown. The aims of this systematic review are to find and critically appraise CPGs for the acute treatment of LALS in adults. Methods: Several medical databases were searched. Two authors independently applied inclusion and exclusion criteria. The content of each CPG was critically appraised independently, by three authors, using the Appraisal of Guidelines for REsearch and Evaluation (AGREE II) instrument online version called My AGREE PLUS. Data related to recommendations for the treatment of acute LALS were abstracted independently by two reviewers. Results: This study found CPGs for physicians and physical therapists (Netherlands), physical therapists, athletic trainers, physicians, and nurses (USA) and nurses (Canada and Australia). Seven CPGs underwent a full AGREE II critical appraisal. None of the CPGs scored highly in all domains. The lowest domain score was for domain 5, applicability (discussion of facilitators and barriers to application, provides advice for practical use, consideration of resource implications, and monitoring/auditing criteria) achieving an exceptionally low joint total score of 9% for all CPGs. The five most recent CPGs scored a zero for applicability. Other areas of weakness were in rigour of development and editorial independence. Conclusions: The overall quality of the existing LALS CPGs is poor and majority are out of date. The interpretation of the evidence between the CPG development groups is clearly not consistent. Lack of consistent methodology of CPGs is a barrier to implementation. Systematic review: Systematic review registered with PROSPERO ( CRD42015025478 ).
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Crioterapia é um recurso comumente utilizado para tratamento de lesões agudas músculo-esqueléticas, principalmente as lesões relacionadas ao esporte. A praticidade e o baixo custo da crioterapia somada aos benefícios terapêuticos induzidos pela mesma tornaram-na um recurso bastante difundido na prática clínica fisioterápica, entretanto, tem sido utilizada de forma indiscriminada. Frente a isso, este estudo buscou esclarecer o papel da crioterapia no trauma agudo, a fim de embasar cientificamente a utilização desse recurso em tais situações e correlacionar as principais indicações terapêuticas da crioterapia no tratamento de traumas agudos aos objetivos, aos métodos, as técnicas de aplicação e aos resultados obtidos. Para realização deste estudo foram realizadas pesquisas em periódicos e livros da biblioteca da Pontifícia Universidade Católica de Minas Gerais, Campus Coração Eucarístico, e nas bases de dados Medline, PEDro, Pubmed e Scielo. Existem evidências da crioterapia para alívio de dor no pós-trauma imediato e possível influência da reação inflamatória aguda, entretanto, 75% dos estudos foram realizados em sujeitos saudáveis. Com base nesta revisão da literatura, sugere-se que os benefícios da crioterapia no trauma agudo estão relacionados principalmente ao controle álgico e à prevenção e/ou diminuição da hipóxia secundária ao processo inflamatório.Palavras-chave: crioterapia, resfriamento tecidual, dor, lesão aguda, lesão de tecido mole.
Article
Context: Allied health care professionals commonly apply cryotherapy as treatment for acute musculoskeletal trauma and the associated symptoms. Understanding the impact of a tape barrier on intramuscular temperature can assist in determining treatment duration for effective cryotherapy. Objective: To determine whether Kinesio® Tape acts as a barrier that affects intramuscular temperature during cryotherapy application. Design: A repeated-measures, counterbalanced design in which the independent variable was tape application and the dependent variable was muscle temperature as measured by thermocouples placed 1 cm beneath the adipose layer. Additional covariates for robustness were BMI and adipose thickness. Setting: University research laboratory. Participants: 19 male college students with no contraindications to cryotherapy, no known sensitivity to Kinesio® Tape, and no reported quadriceps injury within the past six months. Intervention: Topical cryotherapy: crushed-ice bags of 1 kg and 0.5 kg. Main outcome measures: Intramuscular temperature. Results: The tape barrier had no statistically significant effect on muscle temperature. The pattern of temperature change was indistinguishable between participants with and without tape application. Conclusions: Findings suggest health care professionals can combine cryotherapy with a Kinesio® Tape application without any need for adjustments to cryotherapy duration.
Article
Although icing treatment has been well accepted as aftercare in sports fields, the detailed mechanisms of the treatment is not fully understood. In this study, we investigated the effect of icing treatment on the recovery process of rat plantaris muscles with artificially induced muscle damage. Sixty male Wistar rats (8-weeks-old) were randomly assigned to three groups; control (CTL), bupivacaine-injected (BPVC), and icing treatment after BPVC (ICE). Icing treatment was applied for 20 min immediately after BPVC, and the treatment was used once per day for 3 days. The plantaris muscles were removed at 3, 7, 15, and 28 days after the muscle damage, then immunohistochemical and real time RT-PCR analysis were performed. In histochemical analysis, although significant changes were found in the relative muscle weight, cross-sectional area of muscle fiber, percentage of muscle fiber with central nuclei, and expressed immature myosin heavy chain isoforms after muscle damage, as compared to the CTL group, no differences were found between BPVC and ICE groups. In mRNA expression analysis, the ICE group had a significantly lower value of MyoD than the BPVC group at 3 days after the damage. Expression of IL-6 mRNA, which relates to muscle inflammation, indicated significantly higher value in BPVC, but not in ICE, than CTL groups at 7days after the damage. Furthermore, BKB2 receptor, which relates to acute muscle soreness, indicated a significantly higher expression in BPVC than ICE groups at 3 days after the damage. These results suggest that icing treatment is effective to suppress muscle inflammation and soreness at an early stage of recovery from damage, but not effective for muscle regeneration at a later stage.
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Introduction: Physical agents are all of the physical elements that physiotherapists use to intervene in the body with curative intent. However, the increase in scientific publications has allowed greater knowledge to be gained on the effectiveness of certain therapeutic agents in relation to pain. Material and methods: We performed a broad, systematic search of Pubmed (Medline), the Physiotherapy Evidence Database (PEDro) and the Centre for Reviews and Dissemination (D.A.R.E) between August 1 and November 1, 2008 with the following criteria: studies published since 2003, written in English or Spanish, and performed in humans. Only meta-analyses, systematic reviews, randomized controlled trials and clinical practice guidelines were accepted. Results: Of the 2477 studies that could potentially have been included, only 30 met the inclusion and exclusion criteria. Conclusions: Further investigation is needed into commonly used physical agents. Nevertheless, there is a good level of evidence to support the use of certain therapeutic agents in some painful conditions.
Article
Introduction: Cryotherapy is an alternative to Superficial Thermotherapy based on the application of cold as a therapeutic agent, although it is quite clear it is widely used for pain relief. However, only relies on indirect mechanisms of action and without a scientific basis to support its clinical application. Based on this an analysis will be made of the evidence regarding the effectiveness of Cryotherapy by means of a Systematic Review of Randomized Controlled Trials. Objective: To determine if there is scientific evidence to endorse the analgesic effect of Cryotherapy for the management of Musculoskeletal Pain. Strategy of Search: The words/phrases included in the search were, Randomized Controlled Trials (RCTs), Systematic Reviews (SR) and Metaanalysis (MT), the databases used were: MEDLINE/PubMed, PubMed Central, ScienceDirect, Biomed Central, Cochrane Library Plus and DARE. Results: We selected a total of eight studies, including Randomized Controlled Trials and Systematic Reviews. Conclusions: There is moderate evidence supporting that the use of Cryotherapy reduces pain and improves recovery times in ankle sprain and soft tissue injuries associated with sport, but there is limited evidence for its use in Knee Osteoarthritis, Rheumatoid Arthritis and Low Back Pain Syndrome.
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Due to complicated structure of ankle, it is exceptionally susceptible to injuries, of which one of the most common is a sprain. The sprain involves soft-tissue injuries that, depending on their level of seriousness, are categorized as first-, second- or third-degree sprains. The main goals of rehabilitation in the acute phase after the injury include reduction of pain, swelling and hematoma, as well as prevention from secondary injuries. During the subacute phase the emphasis should be put on restoring the joint’s function and its range of motion, as well as on gentle loading of the joint. Proprioception training, strength and stretching exercises should also be introduced. The next stage, during which the reconstruction of the damaged tissues takes place, involves the implementation of gradual progressive loading and the variety of earlier introduced procedures. In the final phase of rehabilitation, it is vital to reassure that the patient is able to return to full activity, especially if he or she is an athlete. Therefore, functional testing such as the Dorsiflexion Lunge Test or The Star Excursion Balance Test may be of help. The main predisposing factor for an ankle sprain is a previous injury of the same type. It is due to the fact that such an injury leads to impaired proprioceptive function and impaired postural control. Improper rehabilitation or the lack of thereof may cause the development of chronic ankle instability, which substantially reduces the chances of physical activity and the patient’s quality of life. The implementation of adequate preventive measures based on employing external stabilisers and neuromuscular training appears to be essential. The objective is to regain a good sense of proprioception as well as muscle reaction time within the ankle joint.
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Introduction. A structured and rigorous methodology was developed for the formulation of evidence-based clinical practice guidelines (EBCPGs), then was used to develop EBCPGs for selected rehabilitation interventions for the management of low back pain. Methods. Evidence from randomized controlled trials (RCTs) and observational studies was identified and synthesized using methods defined by the Cochrane Collaboration that minimize bias by using a systematic approach to literature search, study selection, data extraction, and data synthesis. Meta-analysis was conducted where possible. The strength of evidence was graded as level I for RCTs or level II for nonrandomized studies. Developing Recommendations. An expert panel was formed by inviting stakeholder professional organizations to nominate a representative. This panel developed a set of criteria for grading the strength of both the evidence and the recommendation. The panel decided that evidence of clinically important benefit (defined as 15% greater relative to a control based on panel expertise and empiric results) in patient-important outcomes was required for a recommendation. Statistical significance was also required, but was insufficient alone. Patient-important outcomes were decided by consensus as being pain, function, patient global assessment, quality of life, and return to work, providing that these outcomes were assessed with a scale for which measurement reliability and validity have been established. Validating the Recommendations. A feedback survey questionnaire was sent to 324 practitioners from 6 professional organizations. The response rate was 51%. Results. Four positive recommendations of clinical benefit were developed. Therapeutic exercises were found to be beneficial for chronic, subacute, and postsurgery low back pain. Continuation of normal activities was the only intervention with beneficial effects for acute low back pain. These recommendations were mainly in agreement with previous EBCPGs, although some were not covered by other EBCPGs. There was wide agreement with these recommendations from practitioners (greater than 85%). For several interventions and indications (eg, thermotherapy, therapeutic ultrasound, massage, electrical stimulation), there was a lack of evidence regarding efficacy. Conclusions. This methodology of developing EBCPGs provides a structured approach to assessing the literature and developing guidelines that incorporates clinicians' feedback and is widely acceptable to practicing clinicians. Further well-designed RCTs are warranted regarding the use of several interventions for patients with low back pain where evidence was insufficient to make recommendations.
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Cryotherapy is often used to affect the muscle underlying skin and subcutaneous tissues. However, the relationship between the penetrative ability of various cryotherapy methods and treatment time is not thoroughly understood. The purpose of this study was to measure muscle temperature responses during two frequently used cryotherapy techniques. A 23-gauge hypodermic needle microprobe was inserted to one-half skin-fold thickness plus 1 cm into the medial aspect of the gastrocnemius muscle of 14 subjects. Two groups of seven subjects each were measured for temperature changes during ice bag or ice massage treatment. Each treatment consisted of a 15-minute application of the selected method. A significant difference between the two methods was observed (t = -2,157, p < or = 0.05). Ice massage achieved its lowest temperature in an average of 17.9 +/- 2.4 minutes, while ice bag reached its lowest temperature in 28.2 +/- 12.5 minutes. Ice massage appears to cool muscle more rapidly than ice bag.
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Relatively few studies have been performed to examine the effectiveness of different methods of treatment for the inversion ankle sprain. In this study, restoration of function following a grade II inversion sprain was compared among 34 subjects who received one of three methods of treatment, each of which incorporated an Air-Stirrup brace. The methods included uniform compression provided by elastic tape, focal compression provided by a U-shaped device, and focal compression with simultaneous cryotherapy. Although the results failed to demonstrate statistical significance at the .05 level (p = .055), the two groups that received focal compression attained each of nine levels of function in fewer days than the group that received uniform compression. The results of this study indicate that focal compression appears beneficial, but increased frequency and duration of cryotherapy does not appear to enhance the rate of recovery following an inversion ankle sprain.
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Two-factor repeated measures design. To compare the effects of a 20-minute cold application to the effects of a 20-minute cold application followed by 20 additional minutes of intermittent cold on forearm blood flow over a 60-minute period. The appropriate duration of cold application as a therapeutic modality following soft tissue trauma is an important clinical question because the goal of using this modality is to limit edema, decrease pain, and produce effective muscle relaxation without causing cold-induced reactive vasodilatation or nerve damage. Thirteen subjects (mean age, 21.46 +/- 4.01 years) volunteered to participate in this study. A bilateral tetrapolar impedance plethysmograph was used with venous occlusion to measure changes in local limb blood volume at the forearm for a period of 60 minutes under 2 conditions: Condition 1: Prolonged intermittent cold application (20 minutes ice application; 10 minutes off; 10 minutes ice on; 10 minutes off; 10 minutes ice on); Condition 2: Cold followed by application of a room-temperature pack of equal weight to the ice bag (20-minute ice application; 10 minutes off; 10 minute room-temperature pack on; 10 minutes off; 10-minute room-temperature pack on). A significantly lower blood flow was noted during the last 10 minutes of Condition 1 compared with Condition 2. The findings of this study indicate that blood flow is reduced when a prolonged intermittent cold application (Condition 1) is used compared to a single cold application (Condition 2).
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The Quality of Reporting of Meta-analyses (QUOROM) conference was convened to address standards for improving the quality of reporting of meta-analyses of clinical randomised controlled trials (RCTs). The QUOROM group consisted of 30 clinical epidemiologists, clinicians, statisticians, editors, and researchers. In conference, the group was asked to identify items they thought should be included in a checklist of standards. Whenever possible, checklist items were guided by research evidence suggesting that failure to adhere to the item proposed could lead to biased results. A modified Delphi technique was used in assessing candidate items. The conference resulted in the QUOROM statement, a checklist, and a flow diagram. The checklist describes our preferred way to present the abstract, introduction, methods, results, and discussion sections of a report of a meta-analysis. It is organised into 21 headings and subheadings regarding searches, selection, validity assessment, data abstraction, study characteristics, and quantitative data synthesis, and in the results with "trial flow", study characteristics, and quantitative data synthesis; research documentation was identified for eight of the 18 items. The flow diagram provides information about both the numbers of RCTs identified, included, and excluded and the reasons for exclusion of trials. We hope this report will generate further thought about ways to improve the quality of reports of meta-analyses of RCTs and that interested readers, reviewers, researchers, and editors will use the QUOROM statement and generate ideas for its improvement.
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Cold packs are commonly used by clinicians, trainers, and others, often as an interim treatment for many acute conditions, but the extent of temperature change associated with this form of treatment remains poorly understood. In 16 healthy male and female volunteers aged 25.4 +/- 3.6 yr, we monitored skin temperature, and recorded the temperature of the quadriceps muscle at 1, 2, and 3 cm depths below the skin, before, during, and after 20 min of cold pack treatment. The results revealed a slight rise in temperature at all four levels during the 5 min pretreatment period, but significant temperature falls at the skin and 1 cm levels beginning from 8 min of treatment (P < 0.001). There was no significant change in tissue temperature at the 2.0 cm or 3.0 cm depths throughout treatment. However, after treatment, cutaneous temperature and the temperature at 1.0 cm depth rose rapidly, returning to baseline levels at variable intersubject times. As these superficial temperatures rose, there were concurrent falls in the temperatures at the 2.0 cm and 3.0 cm levels. Thus, the deeper tissues lost heat (cooled) simultaneously as the superficial tissues rewarmed; to the extent that 40 min after treatment, the deeper levels were cooler than the cutaneous and 1.0 cm levels. 1) Cold pack therapy produces significant temperature falls in cutaneous and subcutaneous superficial tissues without directly changing the temperature of tissues at or more than 2.0 cm below the skin; and 2) the temperature gradients of both layers of tissue reverses after treatment, indicating that the deep tissue beneath is at least one of the sources of heat used to rewarm the cooled superficial tissue. The latter finding underscores the importance of the hemodynamic interchange between superficial and deep tissues, and offers an explanation for the reduction of pain, muscle spasm, and edema observed with cold therapy in several clinical situations.
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Despite the long history of using cryotherapy to control edema, we found no randomized, controlled studies providing evidence to substantiate this common clinical practice. The purpose of this study was to determine whether cold water immersion affects edema formation following blunt injuries in rats. The feet of 16 rats were traumatized after hind limb volumes were determined. Four 30-minute treatments of cold water immersion (12.8 degrees C to 15.6 degrees C, 55 degrees F to 60 degrees F), interspersed with four 30-minute rest periods, began immediately after trauma to one randomly selected hind limb of each rat. The limb remained in a dependent position during all treatments, rest periods, and volumetric measurements. Sixteen anesthetized Zucker Lean rats were used in the study. Limb volumes were measured after each treatment and rest period for a total of 4 hours. The volume of treated limbs was significantly smaller (p < .05) than the volume of untreated limbs after the first treatment and remained smaller throughout the experiment. Immersing rat limbs in 12.8 degrees C to 15.6 degrees C (55 degrees F to60 degrees F) water immediately after blunt injury was effective in curbing edema formation.
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While ice and compression wraps are commonly used to treat musculoskeletal injuries, the literature describing intramuscular temperatures has not addressed the combination of ice and compression wraps. The purpose of this study was to evaluate intramuscular temperatures at three sites on the anterior thigh (skin surface, 1 cm below the fat layer, and 2 cm below the fat layer) using both ice and compression wraps. Temperatures were recorded in 11 subjects with an isothermex, using implantable and surface thermocouples. Each subject was tested under four conditions: control, compression only, ice only, and ice + compression according to a balanced Latin square. Surface and intramuscular temperatures were recorded at 30 second intervals during 5 minutes of preapplication, 30 minutes application, and 20 minutes postapplication. A repeated measures ANOVA and Duncan post hoc tests were used to evaluate peak temperature differences between the treatment conditions and the depths of measurement. Both ice alone and ice + compression produced significant cooling at all three depths (F(6,60) = 168.5, p<.0005). Likewise, during the 20-minute postapplication period, these temperatures did not return to their preapplication levels. The compression-only condition produced significant warming at the skin surface, but did not have any effect on intramuscular temperature. At all depths, the ice + compression condition produced significantly cooler temperatures than ice alone. We suggest that compression increases the effectiveness of ice in reducing tissue temperatures. Therefore, ice combined with compression should be more effective than ice alone in reducing the metabolism of injured tissue. This provides an additional rationale for combining ice with compression in treating acute musculoskeletal injuries.
Article
Background and purpose: Assessment of the quality of randomized controlled trials (RCTs) is common practice in systematic reviews. However, the reliability of data obtained with most quality assessment scales has not been established. This report describes 2 studies designed to investigate the reliability of data obtained with the Physiotherapy Evidence Database (PEDro) scale developed to rate the quality of RCTs evaluating physical therapist interventions. Method: In the first study, 11 raters independently rated 25 RCTs randomly selected from the PEDro database. In the second study, 2 raters rated 120 RCTs randomly selected from the PEDro database, and disagreements were resolved by a third rater; this generated a set of individual rater and consensus ratings. The process was repeated by independent raters to create a second set of individual and consensus ratings. Reliability of ratings of PEDro scale items was calculated using multirater kappas, and reliability of the total (summed) score was calculated using intraclass correlation coefficients (ICC [1,1]). Results: The kappa value for each of the 11 items ranged from.36 to.80 for individual assessors and from.50 to.79 for consensus ratings generated by groups of 2 or 3 raters. The ICC for the total score was.56 (95% confidence interval=.47-.65) for ratings by individuals, and the ICC for consensus ratings was.68 (95% confidence interval=.57-.76). Discussion and conclusion: The reliability of ratings of PEDro scale items varied from "fair" to "substantial," and the reliability of the total PEDro score was "fair" to "good."
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The use of hypothermia, in the form of cold applications, on acute traumatized soft tissues is beneficial. This beneficial effect appears to be in limiting the magnitude of injury rather than beneficially altering the inflammatory reaction per se. Two factors act to reduce the magnitude of injury. Hypothermia controls the size of hematoma formation thereby decreasing the amount of waste material that must subsequently be removed from the injury site. This is accomplished through vasoconstriction and increased blood viscosity, both of which slow down blood flow. With less blood flowing, less can escape into the damaged tissue. Hypothermia reduces secondary hypoxic injury by reducing the need for oxygen in the tissues that survived the initial trauma. Thus the total amount of tissue damaged is less.
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Professor Majno is a foremost philosopher-pathologist in the company of Drs Oliver Wendell Holmes, Claude Bernard, Lewis Thomas, and Ruy Pérez-Tamayo. Dr Joris is a productive bioscientist and specialist in inflammatory and vascular phenomena, exemplified in sparkling chapters. Their book is replete with excellent original or borrowed gross and photomicrographs, 27 color plates, x-rays, scans, electron micrographs, immunohistochemical tests, and many outstanding original or adapted diagrams of cells and tissue reactions, graphs, flow charts, and tables that make splendid learning and teaching aids. Some 4500 references are provided, from the time of Hippocrates to the present, quite a few from 1995 and 1996, which takes some doing.Pathobiology examines how and why abnormalities develop, using animal and plant models, cell and tissue cultures, and biologic and biochemical experiments. Philosophers of medicine are rare and to be cherished, for most practicing pathologists have little time to dream. In Cells, Tissues, and
Article
The most common treatment of soft tissue contusions is ice application (cryotherapy). The physiological basis for this therapy is assumed to be cold-mediated vasoconstriction resulting in decreased edema formation and a reduction in overall morbidity. This proposed mechanism has not been tested. The present research examined the hypothesis that cryotherapy following contusion is effective because it reduces microvascular perfusion and subsequent edema formation. The microcirculatory responses to contusion were studied with and without cryotherapy in a chronically instrumented rat model. Initial studies evaluated the immediate effects of cryotherapy on arteriolar and venular diameters and microvascular perfusion (using laser Doppler floxmetry). Variables were measured before and immediately after 20 minutes of cryotherapy. Two additional studies monitored the same microvascular parameters longitudinally in four sets of chronically instrumented animals. Groups of rats studied had contusion or sham contusion with ice treatment or no ice treatment. Measurements were performed repeatedly before and after treatment for 24 hours or 96 hours after contusion/sham contusion. The acute microvascular effects of cryotherapy were vasoconstriction and decreased perfusion. However, when cryotherapy was used as a treatment following contusion/sham contusion, there were no long-lasting microvascular effects of cryotherapy either in the presence or absence of contusion. These results indicate that cryotherapy of striated muscle following contusion does not reduce microvascular diameters or decrease microvascular perfusion. Alternate mechanisms of action for cryotherapy treatment need to be investigated.
Article
The purpose of the present study was to investigate the effects on motor and sensory nerve conduction velocity when ice was applied where the ulnar nerve becomes subcutaneous (medial aspect elbow) and where it is deep to muscle (flexor carpi ulnaris in forearm). It was hoped to determine a relationship between temperature changes, conduction velocity and the percentage of body fat.
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Cooling treatment with 'Cryogel' is compared with the use of crepe bandaging in patients with recent ankle sprains. All patients were followed up regularly and the results appears to favour cooling when it is used in the early period of treatment. Cooling reduced oedema, pain and disability, and shortened the recovery period.
Article
Observations on rabbit hindlimbs following tibial fracture suggest that no regimen of cooling lessens swelling. Temperatures of 5 degrees to 15 degrees led to significantly increased swelling when applied for 24 hours. Increased swelling is the product of the perfusion of vessels rendered hyperpermeable by cold induced ischemia, and indicates that controlled investigations are needed to establish the validity of local cooling in orthopedic management.
Article
Local blood flow was measured with 133Xe clearance technique in eight male distance runners, where one leg was cooled for 20 min by applying two "instant cold packs" on the quadriceps muscle. An initial cooling period after resting was followed by a second cooling period 10 min after running. Skin temperature was maximally reduced after 4.5 min of cooling, both at rest and after running, by 15 degrees C and 14.9 degrees C, respectively. During the first 5 min of cooling no reduction of blood flow was seen. After 10 min of cooling blood flow was significantly reduced in the cooled compared to the control leg by 49% (P less than 0.05) after resting and 34% (P less than 0.05) after running. A maximum reduction of blood flow by 66 and 69% (P less than 0.01), respectively, was seen 10 min after the cooling period. In the event of an acute injury, this delayed reaction of cryotherapy on intramuscular blood flow should be carefully considered.
Article
An investigation designed to assess and compare the effects of therapeutic forms of heat and cold on the pain threshold of the normal shoulder is described. Heat and cold were both found to raise the normal pain threshold significantly, the maximum effect occurring immediately following treatment. Ice therapy was more effective than heat, but following both forms of treatment the effect rapidly declined and after 30 min there was no significant effect on the pain threshold.
Article
This study assesses recovery from ankle sprains. Thirty-seven final participants were categorized ac cording to the severity of their injury and the use of cryotherapy (15 minutes, one to three times per day) versus heat therapy (15 minutes, one to three times per day) for a minimum of three days. Therapy com menced either less than one hour, from one to 36 hours, or greater than 36 hours after the traumatic event. Sprains were graded into five categories based on the severity of the injury, but only two categories, subject to conservative treatment, are considered in this study. The study showed that cryotherapy started within 36 hours after the injury was statistically more effec tive than heat therapy for complete and rapid recov ery. Patients in a group with Grade four sprains (un able to bear weight because of pain) reached full activity in 13.2 days compared to 30.4 days in a group using cryotherapy initiated 36 hours after injury or to 33.3 days in a group using heat therapy. Therefore, early use of cryotherapy, continued with adhesive compression, is an effective treatment of ankle sprains yielding earlier complete recovery than late cryotherapy or heat therapy.
Article
The potential of local cooling to reduce posttraumatic swelling has been assessed on rabbits. A standard crush injury to a forelimb was used as a control model. In a treatment regimen of one hour of cooling following the injury, 30 degrees C proved to perform best, this group having less residual swelling at 24 hours than the 20 degrees C group. Repeated applications of cooling in 3 cycles of one hour of cooling followed by one hour exposure to ambient room air showed residual swelling at 24 hours in both 20 degrees C and 30 degrees C groups. Although no clear-cut clinical directives can be made from the data, it does appear that too much cold or too long application may be deleterious. For these reasons, discretion in the utilization of cold therapy is warranted. Within limits of physiologic conditions, there is empirical evidence for the use of icing treatment of local musculoskeletal trauma.
Article
In a previous study we used technetium-99m bone scans to show that cooling a knee for 20 minutes with a standard ice wrap will decrease soft tissue blood flow by a mean of 26%, and skeletal blood flow and metabolism by 19%. The present study examined the effects of shorter and longer icing periods to determine minimum cooling time for a measurable and consistent decrease, and time to produce maximal decrease within a safe period of icing (< 30 minutes). Thirty-eight subjects were studied. An ice wrap was applied to one knee for an assigned time (5, 10, 15, 20, or 25 minutes). Triple-phase bone scans of knees were obtained; mean percentages of decrease in the iced knee for each of the five time groups at each of the three phases of the bone scan were calculated and compared. Mean decreases of 11.1% in soft tissue blood flow, and 5.1% in skeletal metabolism and blood flow were measured at 5 minutes; maximums of 29.5% and 20.9%, respectively, were obtained at 25 minutes. A small but consistent decrease in soft tissue blood flow and skeletal blood flow and metabolism in a knee appear to be obtained with as little as 5 minutes of ice application. This effect is time-dependent and can be enhanced three- to four-fold by increasing the ice application time to 25 minutes.
Article
Assessing the quality of randomized controlled trials (RCTs) is important and relatively new. Quality gives us an estimate of the likelihood that the results are a valid estimate of the truth. We present an annotated bibliography of scales and checklists developed to assess quality. Twenty-five scales and nine checklists have been developed to assess quality. The checklists are most useful in providing investigators with guidelines as to what information should be included in reporting RCTs. The scales give readers a quantitative index of the likelihood that the reported methodology and results are free of bias. There are several shortcomings with these scales. Future scale development is likely to be most beneficial if questions common to all trials are assessed, if the scale is easy to use, and if it is developed with sufficient rigor.
Article
Whether application of a cold modality following soft tissue trauma causes reactive vasodilation causes reactive vasodilation is an important clinical question since one goal of using a cold modality is to limit edema formation. The purpose of this study was to measure change in local blood volume during application of a cold gel pack following inversion sprain of the ankle. Fifteen volunteers participated as subjects (age range: 18-46 years, mean age: 22.2 years). A bilateral tetrapolar impedance plethysmograph was used with venous occlusion to measure the change in local limb volume at the ankle over a 20-minute period during two conditions: at rest and with cold gel pack application. A significant reduction in local blood volume occurred during cold gel pack application compared with rest. A significant vasodilation response was not observed. The lack of vasodilation response lends support to the clinical use of a cold gel pack following soft tissue trauma when applied to the ankle for a period of up to 20 minutes.
Article
The use of cryotherapy, i.e. the application of cold for the treatment of injury or disease, is widespread in sports medicine today. It is an established method when treating acute soft tissue injuries, but there is a discrepancy between the scientific basis for cryotherapy and clinical studies. Various methods such as ice packs, ice towels, ice massage, gel packs, refrigerant gases and inflatable splints can be used. Cold is also used to reduce the recovery time as part of the rehabilitation programme both after acute injuries and in the treatment of chronic injuries. Cryotherapy has also been shown to reduce pain effectively in the post-operative period after reconstructive surgery of the joints. Both superficial and deep temperature changes depend on the method of application, initial temperature and application time. The physiological and biological effects are due to the reduction in temperature in the various tissues, together with the neuromuscular action and relaxation of the muscles produced by the application of cold. Cold increases the pain threshold, the viscosity and the plastic deformation of the tissues but decreases the motor performance. The application of cold has also been found to decrease the inflammatory reaction in an experimental situation. Cold appears to be effective and harmless and few complications or side-effects after the use of cold therapy are reported. Prolonged application at very low temperatures should, however, be avoided as this may cause serious side-effects, such as frost-bite and nerve injuries. Practical applications, indications and contraindications are discussed.
Article
Thirty healthy patients undergoing lumbar spine surgery were randomly assigned to one of two groups for postoperative pain relief. Group 1 received morphine via patient controlled analgesia and local cooling of the wound by an externally applied cooling pad while group 2 received patient controlled analgesia alone. There was a significant reduction in morphine consumption when local cooling was applied (18.6 mg versus 30.2 mg at 12 h, 29.0 mg versus 49.6 mg at 24 h, p < 0.05). Patients were also significantly more satisfied with their overall postoperative pain management when cooling therapy was used.
Article
Sixty patients with foot or ankle trauma were randomized and treated in three groups. In intermittent impulse compression, an air pad under the foot was inflated every 20 seconds, thus activating the venous foot pump. In continuous cryotherapy, ice water circulates between the ice box and the cold pad. The ice water was changed once per day. In standard therapy, the injured extremity was treated with cool packs, which were changed 4 times per day. Beginning at admission, every 24 hours the circumference was measured around the ankle, midfoot, and forefoot. After 24 hours of treatment, there was a 47% reduction in swelling with the A-V Impulse System, 33% with continuous cryotherapy, and 17% with cool packs. After 4 days of postoperative treatment, the A-V Impulse System reduced the swelling by 74% versus 70% with continuous cryotherapy and 45% with cool packs. Both new methods are preferable to cool packs. Because of the better preoperative results, the A-V Impulse System proved to be the most effective device.
Article
To investigate the effects of cold application with different temperatures on lymph flow in healthy persons and to examine the effects of the combination of cold and compression on lymph vessels. Thirty-nine healthy persons were included in the study, and each served as his or her own control. Water bags (1 degree, 15 degrees, and 32 degrees) with or without 25 mm Hg pressure were applied to the experimental legs for 30 minutes. Cold, pressure, or both were administered by an Aircast-Cryo-cuff (Aircast Europe GMBH, Rosenheim, Germany). Skin temperature was measured with a TESTO 901 (Testoterm GMBH, Leuven, Belgium) precision thermometer. Lymph flow was recorded continuously using lymphoscintigraphy. MANOVA with repeated measures was used for data analysis. As expected, skin temperature dropped relative to the temperature of the water. The migration of the tracer was comparable in both ankles during the first 30 minutes of the experiment (rest). When the water bag was applied, lymph flow increased significantly (p < 0.01). The application of water of 1 degree C without pressure influenced lymph evacuation significantly differently from the other temperatures. The application of pressure of 25 mm Hg influenced lymph evacuation significantly at 1 degree C and 32 degrees C. These results indicate that lymph evacuation at the ankle is influenced significantly when cold water is applied with or without pressure. When pressure is added to the application of water of 32 degrees C, lymph flow will also increase significantly, indicating the importance of pressure in lymph evacuation.
Article
The Quality of Reporting of Meta-analyses (QUOROM) Conference was convened to address standards for improving the quality of reporting of meta-analyses of clinical randomised controlled trials (RCTs). The QUOROM group consists of 30 clinical epidemiologists, clinicians, statisticians, editors, and researchers. In conference, the group was asked to identify items they thought should be included in a checklist of standards. Whenever possible, checklist items were guided by research evidence suggesting that failure to adhere to the item proposed could lead to biased results. A modified Delphi technique was used in assessing candidate items. The conference resulted in the QUOROM statement, a checklist, and a flow diagram. The checklist describes our preferred way to present the abstract, introduction, methods, results, and discussion sections of a report of a meta-analysis. it is organized into 21 headings and subheadings regarding searches, selection, validity assessment, data abstraction, study characteristics, and quantitative data synthesis, and in the results with 'trial flow', study characteristics, and quantitative data synthesis; research documentation was identified for eight of the 18 items. The flow diagram provides information about both the numbers of RCTs identified, included, and excluded and the reasons for exclusion of trials. We hope this report will generate further thought about ways to improve the quality of reports of meta-analyses of RCTs and that interested readers, reviewers, researchers, and editors will use the QUOROM statement and generate ideas for its improvement.
Article
Cryotherapy is a modality commonly used after arthroscopic procedures. We divided 17 patients into two groups after routine knee arthroscopy: 12 patients were immediately treated with ice and 5 control patients were treated without ice for the first hour. In all patients, thermocouple probes were placed intraarticularly into the lateral gutter of the knee. Ice was placed on the operative knees of the treatment group for 2 hours. The control group had no intervention for the 1st hour and then had ice applied for the 2nd hour. Temperatures were continually recorded every minute for 2 hours. The temperature in the treatment group declined significantly, by 2.2 degrees C (95% confidence interval [-3.6 degrees C, -0.72 degrees C]) over the 1st hour and by 0.79 degrees C (95% CI [-1.8 degrees C, 0.18 degrees C]) over the 2nd hour (P = 0.008). The temperature in the control group increased significantly, by 5.0 degrees C (95% CI [2.4 degrees C, 7.5 degrees C]) over the 1st hour (P = 0.006). After ice was applied, the temperature fell significantly, by 4.0 degrees C (95% CI [-8.3 degrees C, 0.26 degrees C]) (P = 0.06). The difference between the temperature decrease in the treatment group and the increase in the control group at 60 minutes was 7.1 degrees C. This is the first rigorously conducted study in human patients that documents a statistically significant decline in intraarticular knee temperature with the application of ice and compression to the skin. The mechanism by which cryotherapy acts must therefore include the cooling effect on the intraarticular environment and synovium.
Article
To study ice therapy guidance in sports medicine textbooks. A systematic search of a convenience sample of textbooks. 45 general sports medicine texts were included in the study. The indices and chapter headings of each text were searched using key words "ice," "cryotherapy," "soft tissue injury," "muscle," and "bruise." In 17 of the textbooks, there was no guidance on the duration, frequency, or length of ice treatment or on the use of barriers between ice and the skin. Advice on treatment duration was given in 28 texts but recommendations differed depending on the particular ice therapy, injury location, or severity. There was considerable variation in the recommended duration and frequency of advised treatments. There was little guidance in the standard textbooks on ice application, and the advice varied greatly. There is a need for evidence-based sport and exercise medicine with a consensus on the appropriate use of ice in acute soft tissue injury.
Article
Ice, compression and elevation are the basic principles of acute soft tissue injury. Few clinicians, however, can give specific evidence based guidance on the appropriate duration of each individual treatment session, the frequency of application, or the length of the treatment program. The purpose of this systematic review is to identify the original literature on cryotherapy in acute soft tissue injury and produce evidence based guidance on treatment. A systematic literature search was performed using Medline, Embase, SportDiscus and the database of the National Sports Medicine Institute (UK) using the key words ice, injury, sport, exercise. Temperature change within the muscle depends on the method of application, duration of application, initial temperature, and depth of subcutaneous fat. The evidence from this systematic review suggests that melting iced water applied through a wet towel for repeated periods of 10 minutes is most effective. The target temperature is reduction of 10-15 degrees C. Using repeated, rather than continuous, ice applications helps sustain reduced muscle temperature without compromising the skin and allows the superficial skin temperature to return to normal while deeper muscle temperature remains low. Reflex activity and motor function are impaired following ice treatment so patients may be more susceptible to injury for up to 30 minutes following treatment. It is concluded that ice is effective, but should be applied in repeated application of 10 minutes to be most effective, avoid side effects, and prevent possible further injury.
Article
Evidence-based practice involves the use of evidence from systematic reviews and randomised controlled trials, but the extent of this evidence in physiotherapy has not previously been surveyed. The aim of this survey is to describe the quantity and quality of randomised controlled trials and the quantity of systematic reviews relevant to physiotherapy. The Physiotherapy Evidence Database (PEDro) was searched. The quality of trials was assessed with the PEDro scale. The search identified a total of 2,376 randomised controlled trials and 332 systematic reviews. The first trial was published in 1955 and the first review was published in 1982. Since that time, the number of trials and reviews has grown exponentially. The mean PEDro quality score has increased from 2.8 in trials published between 1955 and 1959 to 5.0 for trials published between 1995 and 1999. There is a substantial body of evidence about the effects of physiotherapy. However, there remains scope for improvements in the quality of the conduct and reporting of clinical trials.