88 Volume 39
Journal of Athletic Training 2004;39(1):88–94
q by the National Athletic Trainers’ Association, Inc
Does Cryotherapy Hasten Return to
Participation? A Systematic Review
Tricia J. Hubbard; Stephanie L. Aronson; Craig R. Denegar
Pennsylvania State University, University Park, PA
Tricia J. Hubbard, MS, ATC, Stephanie L. Aronson, MS, ATC, and Craig R. Denegar, PhD, ATC, PT, contributed to conception
and design; acquisition and analysis and interpretation of the data; and drafting, critical revision, and ﬁnal approval of the
Address correspondence to Tricia J. Hubbard, MS, ATC, 266 Rec Hall, Department of Kinesiology, Pennsylvania State
University, University Park, PA 16802. Address e-mail to firstname.lastname@example.org.
To search the English-language literature for orig-
inal research addressing the effect of cryotherapy on return to
participation after injury.
We searched MEDLINE, the Physiotherapy
Evidence Database, SPORT Discus, the Cochrane Reviews
database, and CINAHL from 1976 to 2003 to identify random-
ized clinical trials of cryotherapy. Key words used were
therapy, return to participation, cold treatment, ice, injury, sport,
Original research, including outcomes-as-
sessment measures of return to participation of injured sub-
jects, was reviewed using the Physiotherapy Evidence Data-
base (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.
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 cryo-
therapy alone on return-to-participation measures. The relative-
ly poor quality of the studies reviewed is of concern. Random-
ized, controlled clinical studies of the effect of cryotherapy on
acute injury and return to participation are needed to better elu-
cidate the treatment responses.
modalities, cold treatment, outcomes assess-
ment, evidence-based practice
ne goal of all certiﬁed athletic trainers is to return ath-
letes to play as quickly and safely as possible after
injury. To facilitate this goal, numerous rehabilitation
techniques pertaining to the treatment of athletic injuries have
been studied. These studies typically focus on the effect of a
particular modality or treatment on a particular aspect of the
Examples include range of motion,
strength, and balance measurements. Increasingly, the effects
of therapeutic interventions are being assessed through func-
tional and self-report outcomes measures.
starting to address such questions as whether individuals treat-
ed with a particular modality or medication return to work or
sport more rapidly, have a lower incidence of reinjury, or
achieve a desired outcome at a lower cost.
trainers have developed practice guidelines in the form of Na-
tional Athletic Trainers’ Association position statements on
lightning, ﬂuid replacement, and heat illness.
These have of-
fered an excellent starting point; however, to date, no guide-
lines have addressed the efﬁcacy of assessment, treatment, and
rehabilitation techniques. The continued development of the
profession and the need for better patient care require that all
aspects of clinical practice, including prevention, assessment,
treatment, and rehabilitation, be examined and critically ap-
The need for better patient care has lead to evidence-based
Evidence-based practice (EBP) is the inte-
gration of the best research evidence with clinical expertise
and patient values.
It combines practitioners’ clinical exper-
tise at treating a condition with research of the literature on
the treatments of a certain condition. The focus is on patient
values or on the outcomes of patients treated with a certain
modality or rehabilitative technique.
Evidence-based practice starts with a question regarding a
patient problem—for example, ‘‘Is iontophoresis effective in
the treatment of lateral epicondylalgia?’’ Clinicians can then
use past experiences with iontophoresis and begin to search
and critically appraise the literature. Once the articles are ap-
praised and reviewed, conclusions based on the effectiveness
of the treatment can be drawn. The knowledge gained from
these sources must be applied to the patient problem.
dence-based practice is a constantly changing process; new
research is continually conducted, and different results may be
reported. The evidence for the effect of iontophoresis in the
treatment of lateral epicondylalgia may change as new re-
search is published. In addition, reviewing the literature may
not answer all questions. Depending upon the evidence, such
a review may lead to more questions than answers, which can
be a starting point for future research to examine outcomes
and develop an EBP guideline. As new research is conducted,
EBP guidelines must be updated and revised.
Cryotherapy is one of the most commonly applied treat-
Journal of Athletic Training 89
Criteria for selection of articles for review.
Table 1. PEDro* Scale
Eligibility criteria were speciﬁed (no points awarded). Yes No
Subjects were randomly allocated to groups (in crossover study, subjects were randomly allocated in order in which treatments
were received). Yes No
Allocation was concealed. Yes No
The groups were similar at baseline regarding the most important prognostic indicators. Yes No
There was blinding of all subjects. Yes No
There was blinding of all therapists who administered the therapy. Yes No
There was blinding of all assessors who measured at least one key outcome. Yes No
Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups. Yes No
All subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this
was not the case, data for at least one key outcome were analyzed by ‘‘intention to treat.’’ Yes No
The result of between-group statistical comparisons are reported for a least one key outcome. Yes No
The study provides both point measures and measures of variability for at least one key outcome. Yes No
*PEDro indicates Physiotherapy Evidence Database.
ments in the management of acute, athletic-related musculo-
skeletal injuries. Even though cryotherapy is typically applied
clinically along with elevation and compression, we felt it was
important to determine the effect of cryotherapy in isolation
without any confounding variables. This way, the true effect
of cryotherapy could be determined. Numerous studies have
been conducted examining the effect of cryotherapy on tissue
Although it is important to determine the
effect of cryotherapy on various physiologic responses, the
bigger question is, ‘‘What is the effect of cryotherapy on treat-
ment outcome?’’ Does treatment with cryotherapy affect return
to participation? Does speed of return to participation affect
reinjury rate? Is cryotherapy cost effective? When treatment
beneﬁts are identiﬁed, the mechanisms responsible can be fur-
ther explored. Our purpose was to search the English-language
literature for original research addressing the effect of cryo-
therapy on return to participation after injury.
A search of the English-language literature was performed
using MEDLINE, the Physiotherapy Evidence Database,
SPORT Discus, the Cochrane Reviews database, and CINAHL
from 1976 to 2003 for literature related to cryotherapy appli-
cation. Key words used were cryotherapy, return to partici-
pation, cold treatment, ice, injury, sport, edema, and pain.
Research speciﬁc to treatment outcomes after cryotherapy
were identiﬁed. All randomized, controlled clinical trials as-
sessing the effect of cryotherapy were initially examined. (Fig-
ure). All articles were read and the outcomes measures for
each article were recorded. The references of identiﬁed articles
were examined to identify additional articles that may have
been missed during the original search. The majority of re-
searchers examined the effect of cryotherapy on the following
outcomes measures: tissue temperature,
These articles were retained for review
and referenced as appropriate in the discussion section. How-
ever, these articles were not used as part of the analysis, be-
cause they did not examine return to participation. We were
speciﬁcally searching for articles that examined the effect of
cryotherapy on return to participation. Return to participation
was deﬁned as return to sport participation (athletes) or return
to work (typical population) for this study. Articles by authors
who had examined the effect of cryotherapy on return to par-
ticipation were retained for further review.
Physiotherapy Evidence Database Scale
Once we identiﬁed the 4 articles, we used the Physiotherapy
Evidence Database (PEDro) scale to rate the articles. The
PEDro Scale is an evaluation instrument developed for the
Physiotherapy Evidence Database by the Centre for Evidence-
The database provides access to con-
trolled clinical trials and systematic reviews in physiotherapy.
The trials in the database are rated to help users identify stud-
ies of highest methodologic quality. The PEDro scale is a
checklist that examines the ‘‘believability’’ (internal validity)
and the ‘‘interpretability’’ of trial quality. The Scale ‘‘grades’’
the believability of a research report by considering aspects of
study design, such as random allocation; concealment of al-
location; comparability of groups at baseline; blinding of pa-
tients, therapists, and assessors; analysis by intention to treat;
and adequacy of follow-up. The Scale measures the interpret-
ability of the trials by examining between-group statistical
comparisons and descriptions of both point estimates and mea-
sures of variability. The 11-item checklist (Table 1) yields a
maximum score of 10 points if all criteria are satisﬁed. (No
points are awarded for the ﬁrst criterion.)
We chose the PEDro Scale because it has tested reliability
data and was speciﬁcally developed for physiotherapy studies.
90 Volume 39
Maher et al
investigated the reliability of the 11 items of the
PEDro Scale as well as the total score. Raters were volunteer
physical therapists who had been trained in the use of the
Scale. The reliability estimates of the PEDro Scale (intraclass
correlation coefﬁcient 5 .56 for total score for individual rat-
ings and .68 for panel ratings) are similar to those reported
for 3 other commonly used quality scales (Chalmers Scale,
Jadad Scale, and Maastricht List).
The panel ratings tend to
be more reliable than the individual ratings. When using the
PEDro Scale, it would be more beneﬁcial to have a panel of
reviewers than to rely on the judgment of one individual.
However, a panel of reviewers is not part of the PEDro Scale
We independently evaluated the 4 randomized, controlled
trials that met the criteria of return-to-participation measures
using the PEDro Scale. All 3 certiﬁed athletic trainers read the
4 articles separately and assessed them for each of the 11 cri-
teria speciﬁed by the PEDro Scale. Scores were recorded, and
then we met to review the scores. Full consensus was achieved
over the scores given to the 4 articles.
Scores on the PEDro Scale ranged from 2 to 4 of a maxi-
mum 10 points (Table 2). Authors of two of the 4 articles
reported patients returned to play or full function faster with
immediate cryotherapy when compared with late cryotherapy
or no cryotherapy. The third set of authors
quicker return to participation; however, they attributed this
result to the application of external compression rather than
cryotherapy. The fourth set
reported no statistical differences
in return to participation, but a closer look at the data dem-
onstrated that the greater the severity of ankle sprain, the better
the effect of cryotherapy on return to participation.
Hocutt el al
compared the effects of cryotherapy applied
immediately after injury, 1 to 36 hours after injury, and 48
hours after injury and thermotherapy in the treatment of ankle
sprains. Grade of ankle injury was based on level of function
at the start of the study. Grades ranged from 1 (functional) to
5 (requiring surgery). All participants in the study were clas-
siﬁed as having grade 3 or 4 ankle function. When a subject
reached grade 1, we considered that returning to participation.
The study reported that cryotherapy started within 36 hours
after the injury was statistically more effective than heat ther-
This article scored 2/10 on the PEDro Scale. The eligibility
criteria were speciﬁed by including subjects with grade 3 and
4 ankle sprains and excluding those with fractures. The groups
were similar at baseline with regard to the most important
prognostic indicators (degree of ankle sprain). All subjects re-
ceived some form of treatment, even though there was no true
control group. This article was awarded 1 point for having the
intention to treat all subjects. An intention-to-treat analysis
means that, when subjects did not receive treatment as allo-
cated (or were part of the control condition) and when mea-
sures of outcome were available, the analysis was performed
as if subjects received the treatment or control condition al-
located to them.
Basur et al
compared crepe-bandaging treatment with
treatment with cryotherapy and crepe bandaging for 48 hours
postinjury. Subjects were given a severity-of-ankle-injury
score (0 to 6) based on their signs and symptoms when they
visited the emergency room. They were assigned to treatment
with cryotherapy, crepe bandaging, and a layer of tubular com-
pression bandage or to a control group treated with the crepe
bandaging only. Although a signiﬁcant difference between
groups was reported, the results of the speciﬁc statistical anal-
yses were not provided. Of the subjects treated with cryother-
apy, 42.1% recovered by the second day and 84.2% by the
7th day of follow-up. In the control group, recovery rates were
29.1% and 60.6%, respectively.
This paper was graded 3/10 on the PEDro Scale. The in-
vestigators measured at least 1 key outcome from more than
85% of the subjects initially allocated to the groups. Thus, of
the subjects initially enrolled in the study, 85% received treat-
ment, and the dependent variable of interest (return to partic-
ipation) was measured. All 60 subjects initially placed in the
treatment group received treatment. Inclusion criteria based on
this point system were not speciﬁed. Full function was deﬁned
as the number of days to return to work.
Wilkerson and Horn-Kingery
examined the treatment of
grade II inversion ankle sprains with different modes of com-
pression and cryotherapy. Subjects were randomly assigned to
1 of 3 treatment groups, which differed based on the type of
compression they received. The authors assessed ankle func-
tion with an 11-item, 100-point scale.
A score of 100 points
was considered ‘‘full functional capacity,’’ which we equate
with return to participation. The reliability of the scale is not
currently known. We felt that this was a good objective meth-
od for determining ankle level of function and should be ex-
amined in future research studies. Wilkerson and Horn-Kin-
reported no signiﬁcant differences among the groups.
The lack of signiﬁcant between-group differences may be at-
tributable to low statistical power (1 2b5.58).
This paper scored 3/10 on the PEDro Scale. The authors
speciﬁed the eligibility criteria, measured at least 1 key out-
come (return to participation) in more than 85% of the subjects
initially allocated to the groups, reported the results of be-
tween-group variability, and provided point estimates and as-
sociated variability. Ten of the 34 subjects were unavailable at
some point during data collection, so measurements were not
available for all subjects at all time points.
Laba and Roestenburg
examined the effect of cryotherapy
on return to participation in a group treated with cryotherapy
and a group treated with no cryotherapy. Ankle grading was
based on a level-of-function scale similar to that used by Ho-
cutt et al.
All subjects in the study were classiﬁed as grade
3 or 4 ankle function level. For subjects who were classiﬁed
as having a grade 4 injury and treated with cryotherapy, time
to recovery averaged 7.3 days, versus those treated without
cryotherapy, whose recovery time averaged 10.2 days. How-
ever, subjects with less severe injuries (grade 3) treated with
cryotherapy averaged 4.6 days to recovery, whereas those
treated without cryotherapy recovered in 3.0 days.
It may be
that severity of injury plays a role in the effect of cryotherapy.
Yet, there were no statistical differences in the level of pain,
amount of swelling, or speed of return to participation in those
treated with or without cryotherapy.
This article had the highest score (4/10) of all the articles
reviewed on the PEDro Scale. Subjects were randomly allo-
cated to the 2 groups, and the authors provided baseline com-
parability for all subjects, adequate follow-up, and measures
of variability (standard deviations).
Our review of the 4 randomized, controlled clinical trials
suggests that cryotherapy may be effective in reducing the
Journal of Athletic Training 91
Table 2. Reviewed Articles
Article Injury Model Description of Treatment and Control Groups Return-to-Participation Guidelines Results
(Maximum 5 10)
Ankle sprains, function-
al grades 3 and 4
Group 1: cryotherapy applied within 1 to 36 h of injury with ad-
hesive or Ace wrap (n 5 21)
Group 2: cryotherapy applied after 36 h with adhesive or Ace
wrap (n 5 9)
Group 3: heat treatment applied for at least 3 d postinjury with
Ace wrap (n 5 7)
Level of function graded on a
5-point scale, with 1 5 re-
turn to participation
Cryotherapy started within 36 h
of the injury was statistically
more effective than heat thera-
Basur et al
Ankle sprains (grade
Group 1: cryotherapy applied for 48 h, then crepe bandage (n
Group 2: crepe bandage only (n 5 30)
Patient report of return to
Statistically signiﬁcant improve-
ment in the group treated with
cryotherapy compared with the
group treated without
Grade 2 inversion an-
Group 1: elastic tape with Air-Stirrup brace† (n 5 12)
Group 2: U-shaped, liquid-ﬁlled device (room temperature) with
modiﬁed Air-Stirrup brace (n 5 12)
Group 3: U-shaped, liquid-ﬁlled device (frozen) with modiﬁed
Air-Stirrup brace (n 5 10)
Level of function graded on
100-point scale: rating of 90
points counted as normal
No signiﬁcant differences among
the 3 groups
grades 3 and 4
Group 1: 20-min ice-pack treatment (n 5 14)
Group 2: no ice treatment (n 5 16)
Both groups received ultrasound and basic rehabilitation exer-
Level of function graded on a
5-point scale, with 1 5 re-
turn to participation
No signiﬁcant differences be-
tween groups: cryotherapy
seemed to be more effective
as injury severity increased
*PEDro indicates Physiotherapy Evidence Database.
†Aircast, Summit, NJ.
92 Volume 39
time to return to participation; however, the extremely low
quality of the studies reviewed is of concern. Despite the ex-
tensive use of cryotherapy in the management of acute mus-
culoskeletal injury, few investigators
have actually ex-
amined the effect of cryotherapy alone on return to
participation. The results of 2
of the 4 papers reviewed
suggest that cryotherapy instituted soon after injury may be
effective in speeding return to work or sport activity. One of
the potential limitations of this systematic review is the fact
that only 4 articles were reviewed. However, our initial pur-
pose was to examine the effect of cryotherapy on return to
participation. Numerous studies have been conducted exam-
ining the effect of cryotherapy on various outcomes measures,
such as pain, swelling, and functional activities. We felt it was
necessary to examine return to participation. The small num-
ber of articles reviewed is evidence of how little research is
available that examines the effect of cryotherapy on return to
The major ﬂaw with the study by Hocutt el al
is the lack
of detail in reporting the statistical analysis. The authors pro-
vided the mean number of days for subjects to return to par-
ticipation, which was deﬁned as being able to stand, walk,
climb stairs, and run without pain. They stated that all values
were signiﬁcant to a .05 conﬁdence level by the Scheffe´ meth-
We were unsure whether an analysis of variance was
performed before the analysis with the Scheffe´ method. In
addition, we questioned which post hoc pairwise comparisons
were tested. Also, subjects were not evenly distributed among
groups. The total number of subjects in the immediate cryo-
therapy group was greater than the number in the heat therapy
and late cryotherapy groups combined.
In the study by Basur et al,
the type of work to which the
patients returned was not described. In addition, the patients
in the study were not athletes, unlike the subjects in the Hocutt
and Wilkerson and Horn-Kingery
wanted to include any study that examined return to work or
sport. We felt that this helped to widen the scope of the project.
In clinics, athletes are not the only people being treated with
cryotherapy. Although the results of the Basur et al
are difﬁcult to compare due to the differences in population,
we felt that it was important to include the study in our anal-
Although cryotherapy was examined by Wilkerson and
compression appeared to be the primary fo-
cus of the study. All subjects received some form of cryo-
therapy at least once per day during the acute phase of injury.
Group 1 received uniform compression, whereas groups 2 and
3 received focal compression. Group 2 (U-shaped, liquid-ﬁlled
device at room temperature with modiﬁed Air-Stirrup brace
[Aircast, Summit, NJ]) took an average of 11.67 days to return
to participation, compared with 12.30 days for group 3 (U-
shaped, liquid-ﬁlled, frozen device with modiﬁed Air-Stirrup
brace). The authors stated that the small difference between
group 2 and 3 mean values suggests that the mode of com-
pression had a greater effect on return to participation than did
cryotherapy. However, both groups had U-shaped, liquid-ﬁlled
devices with modiﬁed Air-Stirrup braces. The only difference
between the groups was that group 3’s liquid-ﬁlled device was
frozen. The subjects in group 3 were instructed to exchange a
thawed device for a frozen one at 4-hour intervals throughout
the day during the acute phase. Groups 1 and 2 were both
instructed to ice at least once per day for 20 to 30 minutes. It
may be that the long duration of cryotherapy application was
actually detrimental to return to participation. However, group
3 did return to participation more quickly than group 1, which
led the authors to believe that the focal compression applied
to groups 2 and 3 resulted in quicker return to play than the
cryotherapy treatment. Groups 2 and 3 attained function levels
60 through 90 in approximately 25% fewer days then Group
The confounding effect of compression makes it difﬁcult
to draw deﬁnite conclusions on the effect of cryotherapy.
Laba and Roestenburg
reported no signiﬁcant differences
in return to participation between groups treated and not treat-
ed with cryotherapy after acute inversion ankle sprains. How-
ever, subjects with grade 4 injuries treated with cryotherapy
returned to participation an average of 2.9 days faster then
those not treated with cryotherapy. One limitation of this study
is that subjects underwent other forms of rehabilitation in ad-
dition to either receiving or not receiving cryotherapy. All sub-
jects received ultrasound treatments and performed basic
range-of-motion and strengthening exercises depending on the
severity of injury.
Some variability was noted between the
groups with regard to sets, repetitions, and types of exercises
(resisted versus active). All of these additional variables con-
found the potential effects of cryotherapy. It is difﬁcult to
determine whether cryotherapy was indeed responsible for the
recovery rates of the subjects.
Mechanisms for the Efﬁcacy of Cryotherapy
Because cryotherapy was reported effective in returning
subjects to participation in 3 of the 4 articles, we felt that it
was important to examine the mechanisms for effectiveness.
Two potential mechanisms may be better pain control or re-
duced secondary tissue injury.
The analgesic effect of cryotherapy is one of the primary
reasons clinicians use it in the management of acute muscu-
loskeletal injuries. Slowing of nerve conduction velocity is the
likely mechanism for the analgesic response to cold. Ice re-
duces nerve conduction velocity and slows the stretch reﬂex.
The greatest effect of reduced nerve conduction velocity is
shown in superﬁcial nerves,
and the effect of cold on nerve
conduction velocity may last up to 30 minutes after applica-
tion. When pain is effectively managed, the patient may be
able to begin and progress rehabilitation sooner to address
range-of-motion and strength deﬁcits as well as progress to
full weightbearing and functional activities more rapidly.
Retarding secondary injury is an important theoretic beneﬁt
Secondary tissue death has been attributed
to secondary enzymatic injury and secondary hypoxic injury.
proposed that secondary hypoxic injury is a signiﬁ-
cant problem after injury. Cryotherapy reduces tissue temper-
ature, slowing the rate of chemical reactions and, therefore,
the demand for adenosine triphosphate (ATP).
cellular ATP demand decreases the demand for oxygen, which
leads to longer tissue survival during hypoxia.
the amount of damaged and necrotic tissue, the healing process
can be shortened.
authored an extensive review of secondary tissue
injury. The purpose of the paper was to review the secondary
injury model and incorporate new theories into the model that
will guide further research. It is not currently possible to clear-
ly distinguish primary and secondary tissue damage. No data
are available on the time frame for secondary injury.
also addressed the question, ‘‘Is the efﬁcacy of
short-term cryotherapy explained by reduction or prevention
Journal of Athletic Training 93
of secondary injury in cells not initially damaged by primary
trauma, or is the efﬁcacy explained by rescuing or delaying
the death of the cells that were primarily injured but not ini-
tially destroyed?’’ He also questioned the use of the term ‘‘sec-
ondary hypoxic injury.’’ Based on the deﬁnitions of hypoxia
and ischemia, it is appropriate to use the term ‘‘secondary
ischemic injury.’’ Hypoxia presents the single challenge of in-
adequate oxygen, whereas ischemia presents 3 different inad-
equacies: oxygen, fuel substrates, and waste removal.
3 of these problems may contribute to secondary injury. Short-
term cryotherapy through mechanisms described earlier may
lessen tissue ischemia and, therefore, secondary injury.
Physiotherapy Evidence Database Scale
We chose the PEDro Scale to help us appraise the quality
of relevant articles. It identiﬁes research that is unbiased, in-
terpretable, and valid in an effort to discriminate higher and
lower quality studies. In addition, the quality of an article
gives us an estimate of the likelihood that the results are a
valid estimate of the truth.
At present, more than 50 quality
scales are available to review the methodologic quality of re-
search articles, and for most, the reliability is unknown.
comprehensive list of scales and checklists for assessing qual-
ity of articles has been published by Moher et al.
is a helpful guide for clinicians who wish to learn about as-
sessing the quality of articles.
The studies we reviewed were conducted as long ago as 27
years, with the most recent having been conducted 10 years
ago. During the last decade, research methods in this ﬁeld have
evolved signiﬁcantly. The mean PEDro quality scores of clin-
ical trials published between 1955 and 1959 was 2.8, whereas
trials published between 1995 and 1999 scored on average
The fact that the 4 articles we reviewed scored poorly
on the PEDro Scale does not mean that the results and con-
clusions are invalid. They reﬂect limitations in the research
methods available at the time the studies were conducted. Fur-
ther investigation into the efﬁcacy of cryotherapy in the treat-
ment of musculoskeletal injuries through randomized, con-
trolled clinical trials is, however, clearly warranted.
The ﬁrst question an athlete asks after injury is, ‘‘When can
I return to play?’’ Clinicians should use treatments that max-
imize recovery and minimize both the risk of reinjury and the
cost of care. Most research related to cryotherapy has focused
on the physiologic response to cold application; thus, a void
exists in the area of clinically relevant treatment outcomes.
Randomized, controlled clinical trials need to be conducted to
examine return to participation. Investigators should randomly
allocate participants to groups, conceal allocation, specify el-
igibility criteria, ensure similar baseline measures of subjects,
and report outcome measures from more than 85% of the sub-
jects initially enrolled. Intention-to-treat analysis methods
should be used to evaluate data.
Based on the 4 studies we examined critically for this study,
we conclude that cryotherapy had a positive effect on return
to participation. Even though 2 sets of authors
report a signiﬁcant difference between groups in return to par-
ticipation, they did display a trend in improvement. In the
study by Wilkerson and Horn-Kingery,
all 3 groups received
cryotherapy, with the group receiving the longest duration of
cryotherapy improving faster then 1 group but not faster than
the other. Laba and Roestenburg
reported the greater the se-
verity of ankle sprain, the better the effect of cryotherapy on
return to participation. The confounding effects of compres-
sion and different rehabilitation techniques may have con-
cealed the positive effect of cryotherapy. Therefore, further
research is necessary before the effect of cryotherapy on return
to participation can be fully elucidated.
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