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Does Cryotherapy Hasten Return to Participation? A Systematic Review

Authors:

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.
88 Volume 39
Number 1
March 2004
Journal of Athletic Training 2004;39(1):88–94
q by the National Athletic Trainers’ Association, Inc
www.journalofathletictraining.org
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
article.
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 tjh228@psu.edu.
Objective:
To search the English-language literature for orig-
inal 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 random-
ized clinical trials of cryotherapy. Key words used were
cryo-
therapy, return to participation, cold treatment, ice, injury, sport,
edema,
and
pain.
Data Synthesis:
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.
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 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.
Key Words:
modalities, cold treatment, outcomes assess-
ment, evidence-based practice
O
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
rehabilitative process.
1–3
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.
4,5
Investigators are
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.
4,5
Certified athletic
trainers have developed practice guidelines in the form of Na-
tional Athletic Trainers’ Association position statements on
lightning, fluid replacement, and heat illness.
6
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-
praised.
The need for better patient care has lead to evidence-based
medical practice.
7
Evidence-based practice (EBP) is the inte-
gration of the best research evidence with clinical expertise
and patient values.
7
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.
8
Evi-
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.
30
Table 1. PEDro* Scale
31
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
temperature,
1,2,9–15
blood flow,
1–3,9,16–20
pain,
1,2,9,21–24
and
swelling.
1,2,9,25–29
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.
DATA SOURCES
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,
11–15
blood volume,
16–19
swelling,
25–29
pain,
22–24
functional performance,
1,2
and post-
operative measures.
1,2
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-
Based Physiotherapy.
31
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
Number 1
March 2004
Maher et al
32
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).
32
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.
32
However, a panel of reviewers is not part of the PEDro Scale
guidelines.
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.
DATA SYNTHESIS
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
33,34
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
35
also reported
quicker return to participation; however, they attributed this
result to the application of external compression rather than
cryotherapy. The fourth set
36
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
33
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-
apy.
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.
31
Basur et al
34
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.
34
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
35
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.
35
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-
gery
35
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).
35
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
36
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.
33
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.
36
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.
36
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).
DISCUSSION
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
PEDro*
Scale Score
(Maximum 5 10)
Hocutt et
al
34
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-
py
2
Basur et al
34
Ankle sprains (grade
not reported)
Group 1: cryotherapy applied for 48 h, then crepe bandage (n
5 30)
Group 2: crepe bandage only (n 5 30)
Patient report of return to
work
Statistically significant improve-
ment in the group treated with
cryotherapy compared with the
group treated without
3
Wilkerson
and Horn-
Kingery
35
Grade 2 inversion an-
kle sprains
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
function
No significant differences among
the 3 groups
3
Laba and
Roesten-
burg
36
Inversion ankle
sprains, functional
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-
cises
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
4
*PEDro indicates Physiotherapy Evidence Database.
†Aircast, Summit, NJ.
92 Volume 39
Number 1
March 2004
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
33–36
have actually ex-
amined the effect of cryotherapy alone on return to
participation. The results of 2
33,34
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
participation.
The major flaw with the study by Hocutt el al
33
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-
od.
33
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,
34
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
et al
33
and Wilkerson and Horn-Kingery
35
investigations. We
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
34
study
are difficult to compare due to the differences in population,
we felt that it was important to include the study in our anal-
ysis.
Although cryotherapy was examined by Wilkerson and
Horn-Kingery,
35
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
1.
35
The confounding effect of compression makes it difficult
to draw definite conclusions on the effect of cryotherapy.
Laba and Roestenburg
36
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.
36
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,
21
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.
21
Retarding secondary injury is an important theoretic benefit
of cryotherapy.
37–39
Secondary tissue death has been attributed
to secondary enzymatic injury and secondary hypoxic injury.
Knight
37
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).
37
Decreased
cellular ATP demand decreases the demand for oxygen, which
leads to longer tissue survival during hypoxia.
39
By decreasing
the amount of damaged and necrotic tissue, the healing process
can be shortened.
Merrick
39
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.
Merrick
39
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.
39–41
All
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.
42
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.
32
A
comprehensive list of scales and checklists for assessing qual-
ity of articles has been published by Moher et al.
42
This paper
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
5.0.
43
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.
CONCLUSIONS
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
35,36
did not
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,
35
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
36
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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... 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] . ...
Article
Full-text available
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.
... 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.
... 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.
... 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
Full-text available
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
Full-text available
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
Full-text available
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
Full-text available
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.
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.
Article
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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
Article
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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.
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