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The Use of Ice in the Treatment of Acute Soft-Tissue Injury: A Systematic Review of Randomized Controlled Trials

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There are wide variations in the clinical use of cryotherapy, and guidelines continue to be made on an empirical basis. Systematic review assessing the evidence base for cryotherapy in the treatment of acute soft-tissue injuries. A computerized literature search, citation tracking, and hand searching were carried out up to April 2002. Eligible studies were randomized-controlled trials describing human subjects recovering from acute soft-tissue injuries and employing a cryotherapy treatment in isolation or in combination with other therapies. Two reviewers independently assessed the validity of included trials using the Physiotherapy Evidence Database (PEDro) scale. Twenty-two trials met the inclusion criteria. There was a mean PEDro score of 3.4 out of of 10. There was marginal evidence that ice plus exercise is most effective, after ankle sprain and postsurgery. There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft-tissue injury, and there was no evidence of an optimal mode or duration of treatment. Many more high-quality trials are needed to provide evidence-based guidelines in the treatment of acute soft-tissue injuries.
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Cryotherapy is perhaps the simplest and oldest therapeu-
tic modality in the treatment of acute soft-tissue injuries.
It is proposed that by decreasing tissue temperature, ice
can diminish pain, metabolism, and muscle spasm, mini-
mizing the inflammatory process and thereby aiding
recovery after soft-tissue trauma.
32
The majority of
research studies and reviews to date have used healthy
human subjects to investigate these proposed physiologi-
cal effects. Although there is evidence that cryotherapy
can reduce deep-tissue temperature in both animal
2
and
human subjects,
16,46,65
the degree of cooling seems to
depend on the method and duration of application, the ini-
tial temperature of the ice, and even the depth of subcuta-
neous fat.
40
Few literature reviews have considered the clinical evi-
dence base. Kerr
30
attempted to produce clear, evidence-
based guidelines for an optimal cryotherapy protocol; how-
ever, the majority of recommendations for practice were
finalized by expert consensus. A recent systematic review
of the original literature provided preliminary recommen-
dations for an optimal treatment protocol
40
; however, few
clinical studies were discussed, and conclusions were
derived from studies using only animal or healthy human
subjects. To date, no review has measured the quality of
the study methodology or considered the clinical appropri-
ateness of applied treatments within cryotherapy
research.
The current recommendations in standard textbooks on
the clinical use of ice also have many shortcomings,
39
and
most physicians rely on empirical evidence. The selection
of parameters in a clinical environment continues to be
made pragmatically, and recommendations in review arti-
cles range from 10 to 20 minutes 2 to 4 times per day,
29
up
to 20 to 30 minutes,
60
or 30 to 45 minutes
31,32
every 2
hours. The most recent surveys of clinical practice have
The Use of Ice in the Treatment
of Acute Soft-Tissue Injury
A Systematic Review of Randomized Controlled Trials
Chris Bleakley,*
BSc (Hons), MCSP, Suzanne McDonough,
PhD, MCSP,
and Domhnall MacAuley,
MD, FISM
From the
Rehabilitation Science Research Group, University of Ulster at Jordanstown, Antrim,
Ireland, and the
Department of Epidemiology, Queens University, Belfast, Ireland.
Background: There are wide variations in the clinical use of cryotherapy, and guidelines continue to be made on an empirical
basis.
Study Design: Systematic review assessing the evidence base for cryotherapy in the treatment of acute soft-tissue injuries.
Methods: A computerized literature search, citation tracking, and hand searching were carried out up to April 2002. Eligible
studies were randomized-controlled trials describing human subjects recovering from acute soft-tissue injuries and employing
a cryotherapy treatment in isolation or in combination with other therapies. Two reviewers independently assessed the validity
of included trials using the Physiotherapy Evidence Database (PEDro) scale.
Results: Twenty-two trials met the inclusion criteria. There was a mean PEDro score of 3.4 out of of 10. There was marginal evi-
dence that ice plus exercise is most effective, after ankle sprain and postsurgery. There was little evidence to suggest that the
addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies
assessed the effectiveness of ice on closed soft-tissue injury, and there was no evidence of an optimal mode or duration of treat-
ment.
Conclusion: Many more high-quality trials are needed to provide evidence-based guidelines in the treatment of acute soft-tis-
sue injuries.
Keywords: ice; cryotherapy; soft-tissue injury; acute
251
* Address correspondence and reprint requests to Chris Bleakley,
University of Ulster, Jordanstown, Rehabilitation Science Research
Group, Shore Road, Newtownabbey, Co. Antrim, BT37OQB Ireland.
The American Journal of Sports Medicine, Vol. 32, No. 1
DOI: 10.1177/0363546503260757
© 2004 American Orthopaedic Society for Sports Medicine
DOCTYPE = ARTICLE
Team Physician’s Corner
252 Bleakley et al. The American Journal of Sports Medicine
identified variations on the optimal mode, duration, and
frequency of ice application,
28,30
yet such factors dictate
the degree of cooling
40
and the potential effectiveness of
treatment. In addition, ice is commonly combined with
compression and elevation, making it difficult to deter-
mine the value of cryotherapy alone.
45,55,61
Although cryotherapy has been promoted in the imme-
diate
18,32,41,43,45,52,60
and rehabilitative
31,32,55
care of soft-tis-
sue injury, the basis for its application at each stage is
quite different. Immediately postinjury, ice is principally
used to reduce metabolism, thereby minimizing secondary
hypoxic injury and the degree of tissue damage.
31,32
In con-
trast, when applied for rehabilitative purposes, it is used
primarily to relieve pain, which facilitates earlier and
more aggressive exercise.
31,32
Currently, many clinicians
do not fully understand the pathophysiological rationale
at each stage and may not be using it to its full advan-
tage.
31
Cryotherapy is an accessible and popular treatment
modality for the physician and layman, and its use must
be supported by high-quality research evidence. Therefore,
the aim of this study is to explore the clinical evidence
base for cryotherapy, and the specific objectives are the fol-
lowing:
1. to identify randomized-controlled studies assess-
ing the effect of cryotherapy on acutely injured
human subjects;
2. to assess for the presence of confounding concomi-
tant therapies;
3. to study the modes, duration, and frequency of
cryotherapy treatments employed and assess for
evidence of an optimal treatment protocol;
4. to identify when cryotherapy was initiated in rela-
tion to the injury and study the goals of treatment
in each study, that is, for immediate care or reha-
bilitation; and
5. to make conclusions on the strength of the evi-
dence supporting the use of cryotherapy in treat-
ing acute soft-tissue injuries and make recommen-
dations for future research.
METHODS
Search Strategy and Selection of Studies
Relevant studies were identified using a computer-based
literature search on a total of eight databases: Medline on
Ovid (1966 to April 2002), Proquest (1986 to April 2002),
ISI Web of Science (1981 to April 2002), Cumulative Index
to Nursing and Allied Health (CINAHL) on Ovid (1982 to
April 2002), the Allied and Complementary Medicine
Database (AMED) on Ovid (1985 to April 2002), the
Cochrane Database of Systematic Reviews, the Cochrane
Database of Abstracts of Reviews of Effectiveness, and the
Cochrane Controlled Trials Register (Central) (last search
April 2002). For the Medline, CINAHL, and AMED data-
bases, the first two levels of the Medline optimal search
strategy
8
were combined with the following medical sub-
ject headings and free-text topic words: surgery,
orthopaedics, sports injury, soft-tissue injury, sprains and
strains, contusion, athletic injury, acute, compression,
cryotherapy, ice, RICE, and cold. The remaining five data-
bases had less sophisticated interfaces; therefore, a differ-
ent search strategy was performed. To maximize the yield
of relevant articles, this strategy sacrificed precision in
favor of sensitivity.
9
A series of 68 small searches were per-
formed on each database by combining 13 keywords (sur-
gery, orthopaedic, sport, injury, soft-tissue, sprain, strain,
contusion, compression, cryotherapy, ice, RICE, and acute)
using Boolean logic (AND). In addition, a smaller search
was undertaken on the Physiotherapy Evidence Database
(PEDro) (1966 to April 2002) using five keywords (ice,
cryotherapy, cold, injury, and surgery). This was supple-
mented with citation tracking of relevant primary and
review articles (n = 63) and all incoming full-text papers
(n = 55). A convenience sample of 10 key journals was also
hand searched to identify articles that may have been
missed in database and reference list searches (Table 1).
To be included within the review, studies had to fulfill
the following conditions: the study should be a random-
ized-controlled trial of human subjects; it should be
published in English as a full paper; subjects should be
recovering from acute soft-tissue injuries or orthopaedic
surgical interventions; therapy should be inpatient, outpa-
tient, or home-based cryotherapy treatment, used either in
isolation or in combination with placebo or other thera-
pies; comparisons should have been made to no treatment,
placebo, a different mode or protocol of cryotherapy, or
other physiotherapeutic interventions; and outcome meas-
ures must have included at least one of the following: func-
tion (subjective or objective), pain, swelling, or range of
movement (ROM).
In the first stage of selection, the titles and abstracts of
all studies were assessed for the above eligibility criteria.
If it was absolutely clear from information provided in the
TABLE 1
Hand Search of Key Journals
Journal Year range of search
British Journal of Sports Medicine 1988 to December 2001
International Journal
of Sports Medicine 1995 to December 2001
Australian Journal
of Sports Medicine 1984 to December 2001
Sports Medicine 1987 to December 2001
Medicine and Science in
Sports and Exercise 1978 to December 2001
Journal of Sports Medicine
and Physical Fitness 1988 to December 2001
Journal of Orthopaedics and
Sports Physical Therapy 1986 to December 2001
Archives of Physical Medicine
and Rehabilitation 1989 to December 2001
Physiotherapy 1988 to December 2001
Physical Therapy 1986 to December 2001
Vol. 32, No. 1, 2004 Ice for Acute Soft-Tissue Injury 253
title and/or abstract that the study was not relevant, it
was excluded. If it was unclear from the available abstract
and/or title, the full-text article was retrieved. Full-text
articles were also retrieved for studies with a relevant title
but no available online abstract. There was no blinding to
study author, place of publication, or results. The primary
researcher assessed the content of all full-text articles,
making the final inclusion/exclusion decisions.
Assessment of Methodological
Quality and Data Extraction
All eligible articles were rated for methodological quality,
using the PEDro scale. Derived from the Delphi list,
62
this
scale consists of an 11-item checklist, configured by expert
consensus to rate the quality of randomized-controlled tri-
als
50
(Table 2). It is routinely used to rate the quality of
randomized-controlled trials on the PEDro
(ptwww.cchs.usyd.edu.au/pedro). Reviewed studies were
awarded one point for each criterion that was clearly sat-
isfied. As criterion 1 is a measure of the study’s external
validity, it was not included in the final PEDro score, giv-
ing each study a possible maximum score of 10 on the
PEDro scale. To increase the accuracy of the PEDro rat-
ings, two independent reviewers assessed the quality of
eligible studies. Disagreement or ambiguous issues, which
arose between the first two raters, were resolved by either
consensus discussion or consultation with a third party.
Data Extraction and Analysis
The primary reviewer extracted all study characteristics
and data into summary tables. The type of acute soft-tis-
sue injury and interventions applied was noted. For each
intervention, the mode, duration, frequency of cryotherapy,
surface temperature of the cooling device, subjects’ tissue
temperature, and concomitant therapies were recorded.
Attempts were also made to determine when cryotherapy
was initiated in relation to the time of the injury and the
specific purpose for its application, that is, for immediate
care or for rehabilitative purposes in conjunction with
therapeutic exercise. Means and standard deviations for
the four key outcome measures were extracted, and where
possible, individual study-effect estimates were calculated.
This took the form of standardized mean differences
(SMD)
24
for continuous data or risk ratios (RR) for dichoto-
mous data, each with 95% confidence intervals (95% CI).
25
RESULTS
From the initial examination of citations yielded from the
literature search, 55 studies were included. After review of
the complete texts, 33 studies were excluded, leaving 22
eligible randomized controlled trials to be included in the
review. Figure 1 shows the Quality of Reporting of Meta-
Analysis (QUORUM) statement flow diagram,
49
summa-
rizing the process of study selection and the number of
studies excluded at each stage, with reasons.
Study Quality
The 10 criteria and final scores assigned to each study are
presented in Table 3. Overall, the source of subjects and
their eligibility criteria were well reported. Randomization
was stringently performed, and only four studies
1,15,63,64
employed unsatisfactory methods. In contrast, a very
small number of studies provided adequate information on
subjects’ baseline data,
11,15,20,35,38
and only three used con-
cealed allocation during subject recruitment.
34,36,38
In gen-
eral, blinded application of treatment intervention was
also poor; none of the studies blinded the therapists
administering therapy, and just one group of subjects
57
was blinded. In addition, in all but four trials
6,19,36,59
there
was insufficient blinding of outcome assessment. Intention
to treat analysis was adequately performed in just one
study,
26
and eight
10,11,27,34,35,47,51,57,64
supplied adequate
TABLE 2
Physiotherapy Evidence Database (PEDro) Scoring Scale
1. Eligibility criteria were specified Yes/No
2. Subjects were randomly allocated in groups 1
3. Allocation was concealed 1
4. The groups were similar at baseline regarding the most important prognostic indicators 1
5. There was blinding of all subjects 1
6. There was blinding of all therapists who administered the therapy 1
7. There was blinding of all assessors who measured at least one key outcome 1
8. Measures of at least one key outcome were obtained from more than 85% of the subjects initially
allocated to groups 1
9. All subjects from whom outcome measures were available received the treatment or control condition
as allocated or, when this was not the case, data for at least one key outcome were analyzed by “intention
to treat” 1
10. The results of between-group statistical comparisons are reported for at least one key outcome measure 1
11. The study provides both point measures and measures of variability for at least one key outcome 1
Total points 10
254 Bleakley et al. The American Journal of Sports Medicine
information on patient dropout. Between-group statistical
comparisons were well reported, however, and the majori-
ty also included measures of group variability. Final val-
ues were low, ranging from 1 to 5, with a mean PEDro
score of 3.4 of 10.
Study Characteristics
The study population, intervention, outcomes, follow-up,
and reported results of the assessed trials were extracted
and tabulated. Twenty-two trials were included, using a
total of 1469 subjects. The sample size ranged from 21 to
143, and the mean number of subjects used was 66.7; how-
ever, only one study
26
undertook a power analysis prior to
commencement of the trial. Patients had a wide variety of
acute injuries. There were no studies using subjects with
muscle contusions or strains, and only five used subjects
with acute ligament sprains.
11,35,47,59,64
The remaining 17
studies used patients recovering from a range of operative
procedures: ACL reconstruction,
1,6,10,15,19,34,51,58
total knee
arthroplasty (TKA),
20,23,27,38,57a
total hip arthroplasty,
57b
knee arthroscopy,
36,63
lateral retinacular release,
4
and
carpal tunnel release (CTR).
26
Table 4 summarizes the mode, duration, and frequency
of cryotherapy; the total cryotherapy treatment time (over-
all dosage); the time cryotherapy was initiated in relation
to the injury; and the number of days of treatment for each
included study. In total, five different modes were used:
crushed or chipped ice, Cryocuff or cold compressive
devices, commercial ice machines, commercial/gel ice
packs, and ice submersion. Five studies
10,47,58,63,64
simply
stated that an ice bag or pack was applied, and 8 stud-
ies
4,10,23,26,34,58,63,64
used more than one mode of cooling dur-
ing the trial. Similarly, the duration and frequency of
cryotherapy treatments were not consistent across stud-
ies. A total of 13 studies applied cryotherapy continuously
after injury, 7 studies employed an intermittent protocol,
and 5 failed to specify the protocol. With such an array of
icing protocols, the total treatment time subjects received
was extremely diverse. For one group of subjects, the
entire course of cryotherapy treatment consisted of just 20
minutes cooling
35
compared to others whose treatment
time ranged from 216
57
to 336 hours.
58
The temperature of the cooling device and the subject’s
tissue temperature reduction were poorly reported.
Although a number of studies
4,10,26,27,34,51,57
using commer-
cial machines stated the temperature of water flowing
through the machine, they failed to provide adequate
information on the actual surface temperature of the cool-
ing device. Skin temperature reduction during treatment
was reported in just one study,
34
with another measuring
intra-articular knee temperature.
51
Three studies
4,20,26
No Hits.
Medline CINAHL Proquest WOS AMED Cochrane
3321 390 5039 4640 130 1819 (CDSR)
183 (DARE)
3644 (CCTR)
Potentially relevant studies retrieved
for detailed evaluation of full text
(n=55)
Studies excluded after evaluation of full text (n
=33)
Animal subjects (n=3)
Healthy human subjects (n=2)
Experimentally induced injury (n=2)
Non-acute injury (n=2)
Controlled trial / Observational trial / Case study
(n=14)
Inadequate outcome measures (n=1)
Variable subject inclusion criteria (n=3)
No cryotherapy treatment applied (n= 4)
Ice treatment standardized across groups (n=2)
Studies eligib le for inclusion in systematic review
(n=22)
Figure 1. The Quality of Reporting of Meta-Analysis (QUO-
RUM) statement flow diagram. CINAHL = Cumulative Index
to Nursing and Allied Health; WOS = Web of Science; AMED =
Allied and Complementary Medicine Database; CDSR = Coch
-
rane Database of Systematic Reviews; DARE = Cochrane
Database of Abstracts of Reviews of Effectiveness; CCTR =
Cochrane Controlled Trials Register.
TABLE 3
Final Physiotherapy Evidence Database (PEDro)
Scores for Included Trials
Criterion no. Total
Author satisfied
a
score
Cote et al.
11
2, 4, 8, 10, 11 5
Michlovitz et al.
47
2, 8, 10, 11 4
Lessard et al.
36
2, 3, 7, 10, 11 5
Hochberg
26
2, 9, 10, 11 4
Healy et al.
23
2, 10 2
Schroder and Passler
58
2, 10, 11 3
Konrath et al.
34
2, 3, 8, 10 4
Whitelaw et al.
63
10 1
Laba
35
2, 4, 8 3
Sloan et al.
59
2, 7, 10 3
Edwards et al.
19
2, 7, 10, 11 4
Cohn et al.
10
2, 8, 10, 11 4
Wilkerson and Horn-Kingery
64
8, 10, 11 3
Ivey et al.
27
2, 8, 10, 11 4
Scarcella and Cohn
57
2, 5, 8, 10, 11 5
Dervin et al.
15
4, 10, 11 3
Barber et al.
1
10 1
Ohkoshi et al.
51
2, 8, 10, 11 4
Bert et al.
4
21
Levy and Marmar
38
2, 3, 4, 10, 11 5
Gibbons et al.
20
2, 4, 10 3
Brandsson et al.
6
2, 7, 10, 11 4
a
Criterion 1 is not included in final PEDro score.
Vol. 32, No. 1, 2004 Ice for Acute Soft-Tissue Injury 255
stated that cryotherapy was initiated immediately after
surgery; however, they failed to provide a quantifiable
time period. Likewise, others stated that cooling began
prior to tourniquet release,
58
in the recovery room,
27
in the
operating theatre,
10,19,57
or after wound closure and dress-
ing application.
1,6,7,38,51
Most studies using subjects post
ankle sprain initiated cryotherapy between day 1 and 3
postinjury.
11,35,47,59
One study
64
initiated cryotherapy in the
acute phases of injury but again failed to state a definite
time period. Few studies reported the specific goals of
cryotherapy, and it is not clear whether cooling was
employed for immediate care or for rehabilitative purpos-
es. Only two studies
11,36
stated that cryotherapy was
applied in conjunction with exercise, for rehabilitative pur-
poses. It seems that the majority of stud-
ies,
1,10,20,26,27,34,38,57,58
despite continuing cryotherapy for
TABLE 4
Cryotherapy Protocol Employed Within Included Studies
a
Total
cryotherapy
time
(overall
Rx duration No. days dosage) Time/place of
Study
b
Mode (hours) No. Rx/day treated (hours) cryotherapy initiation
Cote et al.
11
Water bath + ex’s 0.3 1 3 1 Third day postinjury
Michlovitz et al.
47
Ice pack 0.5 1 3 1.5 1–28 hours postinjury
Lessard et al.
36
Gel pack + ex’s 0.3 4 7 9.3 At home after discharge
Hochberg
26a
Commerical m 12 1 3 36 Immediately after surgery
Hochberg
26b
Crushed ice;
commercial p 0.3 18 3 18 Immediately after surgery
Healy et al.
23a
Cryocuff Unclear
Healy
23b
Crushed ice Unclear
Schroder and Passler
58a
Cryocuff Continuous Continuous 14 336 Prior to tourniquet release
Schroder et al.
58b
Ice bags 3 Unclear
Konrath et al.
34a
Commercial m 3—5 days
post D/C Unclear
Konrath
34b
Crushed ice Unclear
Whitelaw et al.
63a
Cryocuff Unclear
Whitelaw
63b
Unclear
Laba
35
Crushed ice 0.3 1 1 0.3 Day 0–2 since injury
Sloan et al.
59
Commercial p 0.5 1 1 0.5 Within 24 hours of injury
Edwards et al.
19
Cryocuff Continuous Continuous 1.5 36 In operating theatre
Cohn et al.
10a
Commercial m Continuous Continuous 4 96 In operating theatre
Cohn
10b
Ice bag 1 1 In recovery room
Wilkerson and Horn-Kingery
64
Ice pack 0.5 1 Acute phase
c
1.5 Acute stages
c
Wilkerson
64
Commercial p Continuous Continuous Acute phase
c
64 Acute stages
c
Ivey et al.
27
Commercial m Continuous Continuous 3 64 In recovery room
Scarcella and Cohn
57a
Commercial m Continuous Continuous 9 216 In operating theatre
Scarcella
57b
Commercial m Continuous Continuous 9 216 In operating theatre
Dervin et al.
15
Cryocuff Continuous Continuous 2.5 55–60 Unclear
Barber et al.
1
Commercial m Continuous Continuous 3 (POD 1-3) 64 After application of postopera-
3 (POD 4–6) 48 tive dressing
average
Ohkoshi et al.
51
Commercial m Continuous Continuous 2 48 After surgical wound was covered
Bert et al.
4
Commercial m/p Continuous Continuous 1–2 27 Immediately postsurgery in
recovery room
Levy and Marmar
38
Cryocuff Continuous Continuous 3 64 After skin closure and dressing
were applied
Gibbons et al.
20
Cryocuff 6 (at least) 1 13 (at least) 78 Immediately after the surgical
procedure
Brandsson et al.
6
Cryocuff Continuous Continuous 1 24 After surgical wounds were
closed
a
Rx duration = treatment duration; No. Rx/day = number of treatments per day; + ex’s = Exercises incorporated with cooling; commer-
cial m = Commercial icing machine; Commercial p = Commercially produced ice pack; — = information not reported; D/C = discharge; POD
= Postoperative day.
b
The superscripts “a” and “b” after the study reference number depict that a single study applied more than one cryotherapy protocol
c
Acute” stage of injury not specified.
256 Bleakley et al. The American Journal of Sports Medicine
days and even weeks after the immediate stages of trau-
ma, chose not to incorporate functional movements or
exercise.
Outcome Measures
Pain (visual analogue scale and/or analgesic consumption)
was the most common outcome measure, but only two
studies provided adequate data for function.
57,64
Few
dichotomous measures were used, and the majority of
studies recorded continuous measures over short time
periods (for example, 1-week postinjury). The longest
reported follow-ups were measures of pain, swelling, and
ROM recorded at 4 weeks postinjury
58
; however, insuffi-
cient data were available for effect size calculation. The
longest follow-up data from which an effect size could be
calculated was a measurement of knee ROM recorded 2
weeks postsurgery.
38
In total, nine studies
6,19,20,23,34,57-59,63
failed to provide sufficient data for any of the key outcome
measures, and it was not possible to calculate individual
study effect estimates (either SMD or RR).
Effectiveness of Treatment
A total of 12 treatment comparisons were made. Table 5
subgroups the studies according to treatment comparison
and provides the sample size, overall PEDro score, and
effect size estimates for individual studies (SMD, RR).
Fourteen studies
1,4,10,11,15,26,27,35,36,38,47,51,57,64
provided suffi-
cient data for calculation of individual effect sizes (SMD,
RR) for at least one of the key outcome measures. These
values are provided in the right-hand columns, with a pos-
itive SMD or RR representing an effect in favor of the
treatment group (for example, group A if the groups are
compared as A versus B). Any significant differences
between groups reported in the text are based on the P
values (P < 0.05) provided in the original studies.
Although it is evident that a number of studies carried
out the same treatment comparisons, the effect sizes from
individual trials could not be pooled for statistical analy-
sis. This was due to heterogeneity of the study population,
intervention mode and dosage, timing and type of outcome
measures, or insufficient reporting of data.
Ice Versus Heat/Contrast Bath. There was some evi-
dence that cryotherapy was more effective than ther-
motherapy after ankle injury. A single study
11
found that
ice submersion with simultaneous exercises was signifi-
cantly more effective than heat (SMD, 1.38; 95% CI, 0.35
to 2.29) and contrast therapy (SMD, 2.35; 95% CI, 1.13 to
3.37) plus simultaneous exercises, at reducing swelling
between 3 and 5 days post ankle sprain.
Ice Versus Ice and Electrical Stimulation. A single
study
47
compared the effect of ice alone to ice and simulta-
neous high-voltage electrical stimulation after acute ankle
sprains. There was no significant difference when compar-
ing ice alone and ice combined with low-frequency electri-
cal stimulation (28 pulses per second) in terms of swelling
(SMD, –0.47; 95% CI, –1.34 to 0.44), pain (SMD, –0.64; 95%
CI, –1.51 to 0.28), and ROM (SMD, –0.69; 95% CI, –1.56 to
0.24). Similarly, there was no significant difference com-
paring ice alone and ice combined with higher frequency
electrical stimulation (80 pulses per second) in terms of
swelling (SMD, –1.39; 95% CI, –2.3 to 0.36), pain (SMD,
–0.62; 95% CI, –1.5 to 0.31), and ROM (SMD, –1.36; 95%
CI, –2.3 to –0.3).
Ice Versus No Ice. Ice alone seems to be more effective
than applying no form of cryotherapy after minor knee
surgery. A single study
36
compared the effect of an inter-
mittent icing protocol combined with knee exercises to
exercises alone, after minor arthroscopic knee surgery. The
application of ice immediately before a rehabilitation pro-
gram significantly decreased pain as measured by the
affective component of the McGill Pain Questionnaire
(SMD, 0.59; 95 CI, –0.02 to 1.17). The study also reported
that subjects applying cryotherapy used significantly less
prescription and nonprescription analgesia and had a sig-
nificantly better weightbearing status; however, insuffi-
cient data are provided for the calculation of an effect size.
In contrast, there were no significant differences between
groups in terms of knee girth (SMD, 0.35; CI, –0.24 to 0.93)
and knee ROM (SMD, 0.38; CI, –0.21 to 0.97) 1 week post-
surgery.
Ice (Continuous) Versus Ice (Intermittent). Using sub-
jects post-CTR, Hochberg
26
compared the effect of continu-
ous cryotherapy to intermittent 20-minute ice applications
over the first 3 postoperative days. Subjects applying con-
tinuous cryotherapy had a significantly greater decrease
in pain (SMD, 1.09; CI, 0.4 to 1.7) and wrist circumference
(SMD, 2.2; CI, 1.43 to 2.9) in comparison to those using
cryotherapy intermittently. This was the only study to
compare the effectiveness of two different cryotherapy pro-
tocols, and although it appears that continuous cryothera-
py should be the treatment of choice after surgery, the
modes of cryotherapy application were not consistent
across the two groups.
Ice and Compression Versus Ice and Compression. Four
studies
23,34,58,63
compared two different methods of apply-
ing simultaneous compression and cryotherapy, but few
conclusions could be reached. Poor reporting of data meant
that individual effect size could not be calculated for any
of these studies. Furthermore, two studies
58,63
did not pro-
vide adequate information on the mode of cryotherapy, and
all failed to specify the duration and frequency of the ice
application.
Ice and Compression Versus No Ice. There is marginal
evidence that a single simultaneous treatment with ice
and compression is no more effective than no cryotherapy
after an ankle sprain. Laba
35
found that a single applica-
tion of ice and compression, in addition to standard reha-
bilitation treatment (ultrasound, mobility, and propriocep-
tive exercises), produced similar levels of swelling (RR,
0.76; CI, 0.5 to 1.02) and pain immediately posttreatment
(RR, 1.5; CI, 1.24 to 1.76) and at discharge (RR, 0.88; CI,
0.62 to 1.14) when compared to those receiving standard
treatment only. Sloan
59
also found that a single application
of simultaneous ice and compression was as effective as no
treatment in terms of reducing pain, swelling, and ROM
post ankle sprain. Similarly, Edwards
19
found that the con-
Vol. 32, No. 1, 2004 Ice for Acute Soft-Tissue Injury 257
TABLE 5
Effect Size Estimates for Individual Studies
a
Effect size (95% CI)
Intervention Injury
b
N Function Pain Swelling ROM PEDro (10)
Ice vs heat Ankle
11
30 1.38 (0.35–2.29) 5
Ice vs contrast Ankle
11
30 2.35 (1.13–3.37) 5
Ice vs ice + E-Stim (Freq 28 pps) Ankle
47a
30 –0.64 (–1.51 to 0.28) –0.47 (–1.34 to 0.44) (day 1); –0.69 (–1.56 to 0.24) (day 1);
–0.14 (–1.01 to 0.75) (day 3) –0.58 (–1.45 to 0.24) (day 3) 4
Ice vs ice + E-Stim (Freq 80 pps) Ankle
47b
30 –0.62 (–1.5 to 0.3) –1.39 (–2.3 to 0.36) (day 1); –1.36 (–2.3 to –0.3) (day 1);
–0.09 (–0.96 to 0.8) (day 3) –0.39 (–1.3 to 0.5) (day 3) 4
Ice vs No Rx Arth
36
45 0.24 (–0.35 to 0.82) (T);
0.59 (–0.02 to 1.17) (A) 0.35 (–0.24 to 0.93) 0.38 (–0.21 to 0.97) 5
Ice (continuous) vs ice (intermittent) CTR
26
48 1.09 (0.4–1.7) 2.2 (1.43–2.9) 4
I/C vs I/C TKA
23
76 N/A N/A N/A 2
ACL
58
44 N/A N/A N/A 3
ACL
34a
100 N/A N/A 4
Arth
63
102 N/A N/A N/A 1
I/C vs No Rx Ankle
35
30 N/A 1.5 (1.24–1.76);
0.88 (0.62–1.14) 0.76 (0.5–1.02) 3
Ankle
59
143 N/A N/A N/A 3
ACL
19a
63 N/A N/A 4
I/C vs ice ACL
10
54 N/A 4.43 (3.3–5.24);
4.49 (3.41–5.4) 4
I/C vs C (same mode) Ankle
64a
34 –0.14 (–0.97 to 0.7) 3
TKA
27
90 –0.43 (–0.95 to 0.1) 4
TKA
57
24 –0.75 (–1.55 to 0.1) 0.39 (–0.44 to 1.18) 5
ACL
34b
100 N/A N/A N/A 4
ACL
19b
63 N/A N/A 4
ACL
15
78 N/A –0.33 (–0.7 to 0.12) (VAS);
–0.17 (–0.6 to 0.3) (A/gesic);
–0.09 (–0.5 to 0.4) (IV) 3
ACL
1
99 N/A 1.14 (1.0; 1.28) 1
ACL
51a
21 –0.6 (–1.64 to 0.5) (VAS);
0.3 (–0.75 to 1.36) (A/gesic) 1.02 (–0.16 to 2.05) 4
ACL
51b
21 1.21 (0.0–2.2) (VAS) 0.89 (–0.26 to 1.92) 0.8 (–0.27 to 1.9) (A/gesic) 4
THA
57
50 N/A 5
I/C vs C (Diff Mode) LRR
4
110 Overall score:
0.35 (0.27 to 0.42) 2
Ankle
64b
34 0.55 (–0.32 to 1.38) 3
TKA
38
80 0.75 (0.3–1.2) (VAS[D2]); 0.64 (0.19–1.08) (day 7);
0.41 (–0.04 to 0.85) (A/gesic) 0.89 (0.42–1.34) (day 14) 5
TKA
20
60 N/A N/A 3
I/C + P vs P vs I/C and I/A inj ACL
6
50 N/A 4
a
Studies are grouped according to the treatment comparisons employed. A positive standardized mean difference or risk ratio represents an effect in favor of the treatment
group (for example, group A if the groups are compared as A vs B). Effect size = relative risk ratio; ROM = range of movement; PEDro = Physiotherapy Evidence Database; Ankle =
ankle
sprain; — = outcome not measured; E Stim = electrical stimulation; pps = pulses per second; No Rx = no treatment; T = total McGill Questionnaire score; A = affective component
McGill questionnaire score; CTR = carpal tunnel release; I/C = simultaneous ice and compression; Same = mode of compression constant across groups; TKA = total knee arthro-
plasty; N/A = data not available; ACL = anterior cruciate ligament reconstruction; Arth = arthroscopy; I = ice treatment; C = compression; VAS = visual analogue scale; A/gesic =
oral analgesic consumption; I/V = intravenous analgesic consumption; THA = total hip arthroplasty; Diff = mode of compression differed across groups; LRR = lateral retinacular
release; P = placebo; I/A inj = intra-articular analgesic injection.
b
The superscripts “a” and “b” after the study reference number depict that a single study applied more than one cryotherapy protocol
258 Bleakley et al. The American Journal of Sports Medicine
tinuous use of ice and compression had similar benefits to
no treatment in terms of improving pain and ROM when
applied postsurgically; however, insufficient data were
provided for these later two studies.
19,59
Ice and Compression Versus Ice. Only one clinical study
has compared ice and compression to ice alone.
10
The com-
bination of treatments appeared to be significantly more
effective than ice in terms of reducing the amount of intra-
muscular (SMD, 4.43; 95% CI, 3.3 to 5.24) and oral anal-
gesia (SMD, 4.49; 95% CI, 3.4 to 5.4) administered
post–ACL reconstruction. These results must be interpret-
ed with caution, however, as the mode and duration of ice
treatment were not controlled for across groups.
Ice and Compression Versus Compression. The majority
of included studies have tried to disentangle the effects of
ice from compression by comparing a variety of treatment
combinations. In four studies, it was difficult to compare
the efficacy of each modality
4,20,38,64
as the mode of com-
pression differed between the intervention and control
groups. On the contrary, eight studies strictly controlled
for the type of compressive bandages used across compar-
ison groups
1,15,19,27,34,51,57,64
; however, there seemed to be lit-
tle difference in the effectiveness of ice and compression
and compression alone.
Wilkerson
64
found no significant difference in the time of
restricted activity after ankle sprain in subjects treated
with compression alone and simultaneous ice and com-
pression (SMD, –0.14; 95% CI, –0.97 to 0.7). Using subjects
post–ACL reconstruction, others reported no significant
differences between groups in terms of function,
34
pain,
19,34
and swelling
1,19,34
; however, insufficient data were report-
ed and effect size could not be calculated for these out-
comes. Similarly, Dervin
15
found no significant differences
in subjective pain scores (SMD, –0.33; 95% CI, –0.77 to
0.12) and the amounts of intravenous (SMD, –0.09; 95%
CI, –0.53 to 0.35) and oral analgesics (SMD, –0.17; 95% CI,
–0.62 to 0.27). In a group of subjects post-TKA, Ivey
27
found no significant difference between groups with
regard to the amount of injected morphine (SMD, –0.43;
95% CI, –0.95 to 0.1) postsurgery. Scarcella
57
found no sig-
nificant difference in subjects post-TKA in terms of ROM
(SMD, 0.39; 95% CI, –0.44 to 1.18) and the time to inde-
pendent ambulation (SMD, –0.75; 95% CI, –1.55 to 0.1).
The study
57
also reported that the analgesic consumption
in each group was almost identical. Correspondingly, in a
subgroup of patients recovering from total hip arthroplas-
ty, Scarcella
57
reported no significant differences in anal-
gesic consumption postsurgery; however, insufficient data
were provided and effect size could not be calculated.
Only two studies reported significant differences
between subjects treated with ice and compression and
compression alone. Although Barber
1
found no differences
between groups in knee ROM after ACL reconstruction
(RR, 1.14; 95% CI, 1.0 to 1.28), a significantly decreased
analgesic consumption was reported in favor of the ice and
compression group; however, inadequate data were provid-
ed. Again using subjects post–ACL reconstruction,
Ohkoshi
51
treated two groups with simultaneous ice and
compression and a third with compression only. The ice
and compression groups were cooled to slightly different
temperatures using a commercial ice machine (5°C and
10°C). Subjects using less extreme cooling (10°C group)
with concomitant compression had significantly lower sub-
jective pain scores (SMD, 1.21; 95% CI, 0.00 to 2.2) and
analgesic consumption (SMD, 0.88; 95% CI, –0.27 to 1.91)
compared to those using compression alone. In contrast,
there were no significant differences in subjects treated
with simultaneous cooling (5°C group) and compression
and those treated with compression only in terms of sub-
jective pain scores (SMD, –0.6, 95% CI, –1.64 to 0.5) and
analgesic consumption (SMD, 0.3, 95% CI, –0.75 to 1.36). A
better improvement in ROM was observed in the 5°C
(SMD, 1.02; 95% CI, –0.16 to 2.05) and 10°C groups (SMD,
0.89; 95% CI, –0.26; 1.92) when compared to compression
group; however, these differences were not significant.
Therefore, despite eight trials comparing the effective-
ness of ice and compression to compression alone, only
two
1,51
reported significant differences in favor of ice and
compression. Both Barber’s
1
and Ohkoshi et al.’s
51
studies
were of low quality, scoring just 1 out of 10 and 4 out of 10
on the PEDro scoring scale, respectively, and therefore the
strength of their conclusions is limited. Generally, there
was very little evidence to suggest that the addition of ice
to compression has any significant effect. It must be noted,
however, that all but one of the studies
64
were undertaken
postsurgery, and any conclusions are restricted to hospital
inpatients with postsurgical wound dressings.
Ice and Compression Plus Placebo Injection Versus Ice
and Compression Plus Injection Versus Placebo Injection.
Brandsson et al.
6
found that ice and compression plus a
placebo injection were significantly more effective than
placebo injection alone at reducing postoperative pain. The
addition of a pain-killing injection to ice and compression
therapy significantly improved the analgesic effect fur-
ther; however again, no data were provided and effect size
could not be calculated.
DISCUSSION
Cryotherapy continues to be employed in both the clinical
and sporting environments to treat acute soft-tissue
injuries as well as postsurgical patients within a hospital
setting.
42
A number of review articles have advocated the
use of cryotherapy in both of these contexts,
31,41,42,55
and
others have scrutinized its physiological and clinical
effects.
30,40,43,45,52,61
This is the first study to systematically
review the literature, assessing the clinical evidence base
supporting the use of cryotherapy based on the highest
quality research evidence. The review is restricted to
English language, however, and as the inclusion criteria
for study population were broad, some of the information
contained was difficult to compare and synthesize. The
included randomized controlled trials scored an average
PEDro score of only 3.4, and the contrast in treatment pro-
tocols means that comparison within and across studies is
often impossible. Moreover, persistent methodological
problems and the failure of the majority of studies to carry
out a power analysis may prevent wider extrapolation of
evidence.
Vol. 32, No. 1, 2004 Ice for Acute Soft-Tissue Injury 259
Soft-tissue injuries such as contusions, strains, and
sprains are the most common injuries in Gaelic football,
12
soccer,
22
and rugby.
21
To date, however, no randomized
studies have assessed the efficacy of ice in the treatment
of muscle contusions or strains, and only five studies have
assessed the effect of ice on acute ankle sprains. Single
applications of combined ice and compression seem to be
as effective as no treatment after an acute sprain; howev-
er, these conclusions must be taken with caution. Aside
from the paucity of high-quality studies undertaken, this
particular research question may also be subject to a
unique set of problems inherent to cryotherapy research.
Given the strong empirical evidence base and the popular-
ity of cryotherapy treatment with the layman, it may be
difficult to randomize a subject to a “no ice” group. This is
particularly evident in Laba’s
35
study, in which 60% of sub-
jects randomized to the no ice group had already applied
ice as a self-treatment prior to recruitment.
Evidence from a recent systematic review suggested
that intermittent 10-minute ice treatments are most effec-
tive at cooling injured animal tissue and healthy human
tissue.
40
The effectiveness of this particular protocol has
not yet been tested on injured human subjects; however,
Hochberg
26
found that intermittent 20-minute applica-
tions are less effective than continuous ice treatment after
CTR surgery. The strength of the study’s conclusions is
greatly limited, however, as Hochberg
26
crucially failed to
control for the mode of cryotherapy across the continuous
and intermittent groups. No individual study has rigor-
ously compared the efficacy of different modes, durations,
or frequencies of ice treatment, and preliminary recom-
mendations for an optimal cryotherapy protocol cannot be
made.
Other systematic reviews
5
have provided evidence-
based guidelines on optimal treatment parameters by sub-
grouping trials to highlight a dose-dependant pattern.
Although it was the author’s intention to carry this out,
subgrouping trials according to the mode or duration of
cryotherapy was impossible due to clinical heterogeneity
and the large number of trials supplying insufficient treat-
ment detail.
Within clinical practice, ice is commonly combined with
compression and elevation, making it difficult to deter-
mine the value of cryotherapy alone.
45,55,61
A number of
studies have compared a wide range of combinations of ice
and compression in a bid to try and disentangle their rel-
ative efficacy. Only one study
10
compared simultaneous ice
and compression to ice alone. This study does little to sep-
arate and quantify the individual effects of ice and com-
pression as both the modes and durations of cold treat-
ments applied across groups were starkly contrasting.
Twelve studies compared the effectiveness of concomi-
tant ice and compression to compression alone, but only
eight well-controlled studies
1,18,22,30,37,55,61,64
used the same
mode of compression between intervention and control
groups. The initial consensus seems to be that the addition
of ice to compression is no more effective than compression
alone. However, such a conclusion is limited, as in all eight
of these studies, postsurgical dressings or socks were used
to separate the injured area of the body and the cooling
device. The thickness of dressings varied from gauze
57
to
cast padding and an elastic bandage
27
; such barriers have
the potential to mitigate the cooling effect of cold com-
press.
To maximize the therapeutic effects of cryotherapy, an
optimal tissue temperature reduction of 10° to 15°C may
be necessary.
40
Skin temperature reductions to below
13.6°C may be needed to achieve local analgesia,
7
and per-
haps lower tissue temperatures of between 10°C and 15°C
may be required to maximally lower metabolism.
33,56
Generally, the surface temperature of the cooling device
and the subject’s tissue temperature reduction during
treatment were poorly reported in this review. The only
study
34
that monitored skin tissue temperatures during
treatment reported a maximum reduction to just 28°C.
Correspondingly, there is evidence from many stud-
ies
13,14,37,53
that it is difficult to achieve optimal tissue tem-
perature reductions when cooling is applied over postoper-
ative dressings. The interaction between the cooling sur-
face and the subjects’ tissue is vital in determining the
effectiveness of treatment and must be considered in
future studies, particularly within a postsurgical environ-
ment.
There have been some deleterious side effects of
cryotherapy previously documented. A number of case
studies have reported the occurrence of skin burns
54
and
nerve damage
3,17,44,48
after as little as 20 to 30 minutes of
cooling. Within this review, there was just one reported
case of cold-induced nerve palsy, possibly caused by a con-
tinuous 40-minute ice application in the recovery room
postsurgery.
10
None of the other studies reported any inci-
dences of skin burns or nerve palsies, despite applying con-
tinuous ice treatments for between 6 and 226 hours.
Cryotherapy is a versatile modality and may be used in
the immediate
18,32,41,43,45,52,60
and rehabilitative
31,55
phases
of injury management. However, a common source of con-
fusion is the basis for its application at each phase.
Immediately postinjury, ice reduces tissue metabolism,
thereby minimizing secondary hypoxic injury, cell debris,
and edema. The sooner after injury cryotherapy is initiat-
ed, the more beneficial this reduction in metabolism will
be.
31
A number of studies
35,47,59
began cryotherapy between
24 and 48 hours after injury and therefore may not have
optimized this positive physiological effect. It may be eas-
ier to initiate early cryotherapy in studies using surgical
patients. Although most surgical studies stated that
cryotherapy was initiated either immediately after sur-
gery, in the operating theatre, or after dressing and wound
closure, few significant differences were reported. Again,
this may be due to concomitant compression or wound
bandaging mitigating the cooling effect and preventing
adequate metabolic reduction.
Outside the immediate stages of injury management,
cryotherapy may be most effective when combined with
exercise.
31,32
Adequate cooling can reduce pain, spasm, and
neural inhibition, thereby allowing for earlier and more
aggressive exercises. In the current review, many stud-
ies
1,10,20,26,27,34,38,57,58
continued cryotherapy treatment for
days and even weeks after injury but chose not to inte-
grate therapeutic exercise. Although cryotherapy in isola-
260 Bleakley et al. The American Journal of Sports Medicine
tion may reduce the need for analgesics in the subacute
phases of recovery, early exercise may be the most impor-
tant component of treatment.
31,32
Only two studies
11,36
incorporated exercise with cryotherapy, during the suba-
cute phases of recovery, and both recorded results signifi-
cantly in favor of cryotherapy. Nonetheless, it seems that
the majority of studies in this review have not fully con-
sidered the pathophysiological basis of cryotherapy and
may not have used it to its full potential. Future studies
must seek to optimize cryotherapy’s effects at each phase
of injury management to provide clinicians with clearer
evidence of its potential effectiveness and versatility.
CONCLUSION
Many more high-quality studies are needed to ensure that
clinicians and sportsmen are following evidence-based
guidelines in the treatment of acute soft-tissue injuries.
Primarily, these must focus on developing modes, dura-
tions, and frequencies of ice application, which will opti-
mize cryotherapy during immediate and rehabilitative
care. Similarly, an optimal mode and duration of compres-
sion treatment must be highlighted. This evidence will
highlight the respective value of each individual modality
and if appropriate provide the basis of an optimal method
for treatment combination.
REFERENCES
1. Barber AF, McGuire DA, Click S: Continuous-flow cold therapy for
outpatient anterior cruciate ligament reconstruction. Arthroscopy 14:
130–135, 1998
2. Barlas D, Homan CS, Thode HC Jr: In vivo tissue temperature com-
parison of cryotherapy with and without external compression. Ann
Emerg Med 28: 436–439, 1996
3. Bassett FH III, Kirkpatrick JS, Engelhardt DL, et al: Cryotherapy-
induced nerve injury. Am J Sports Med 20: 516–518, 1992
4. Bert JM, Stark JG, Maschka K, et al: The effect of cold therapy on
morbidity subsequent to arthroscopic lateral retinacular release.
Orthopaedic Review 20: 755–758, 1991
5. Bjordal JM, Couppe C, Ljunggren AE: Low level laser therapy for
tendinopathy: Evidence of a dose response pattern. Physical Therapy
Reviews 6: 91–99, 2001
6. Brandsson S, Rydgren B, Hedner T, et al: Postoperative analgesic
effects of an external cooling system and intra-articular bupiva-
caine/morphine after arthroscopic cruciate ligament surgery. Knee
Surg Sports Traumatol Arthrosc 4: 200–205, 1996
7. Bugaj R: The cooling, analgesic and rewarming effects of ice mas-
sage on localized skin. Phys Ther 55: 11–19, 1975
8. Clarke M, Oxman AD, eds: Optimal search strategy for RCT’s.
Cochrane Reviewers Handbook 4.1.4 [updated October 2001];
Appendix 5c. In: The Cochrane Library, Issue 4, 2001. Oxford:
Update Software
9. Clarke M, Oxman AD, eds: Locating and selecting studies. Cochrane
Reviewers Handbook 4.1.4 [updated October 2001]; Section 5.6. In:
The Cochrane Library, Issue 4, 2001. Oxford: Update Software
10. Cohn BT, Draeger RI, Jackson DW: The effects of cold therapy in the
postoperative management of pain in patients undergoing anterior
cruciate ligament reconstruction. Am J Sports Med 17: 344–349,
1989
11. Cote DJ, Prentice WE, Hooker DN, et al: Comparison of three treat-
ment procedures for minimizing ankle sprain swelling. Phys Ther 68:
1064–1076, 1988
12. Cromwell F, Walsh J, Gormley J: A pilot study examining injuries in
elite Gaelic footballers. Br J Sports Med 34: 104–108, 2000
13. Culp RW, Taras JS: The effect of ice application versus controlled
cold therapy on skin temperature when used with postoperative
bulky hand and wrist dressings: A preliminary study. J Hand Ther 8:
249–251, 1995
14. Daniel DM, Stone ML, Arendt DL: The effect of cold therapy on pain,
swelling, and range of motion after anterior cruciate ligament recon-
structive surgery. Arthroscopy 10: 530–533, 1994
15. Dervin GF, Taylor DE, Keene GC: Effects of cold and compression
dressings on early postoperative outcomes for the arthroscopic ante-
rior cruciate ligament reconstruction patient. J Orthop Sports Phys
Ther 27: 403–406, 1998
16. Draper DO, Schulthies S, Sorvisto P, et al: Temperature changes in
deep muscles of humans during ice and ultrasound therapy: An in
vivo study. J Orthop Sports Phys Ther 21: 153–157, 1995
17. Drez D, Faust DC, Evans JP: Cryotherapy and nerve palsy. Am J
Sports Med 9: 256–257, 1981
18. Dyment PG: Management of minor soft tissue trauma in adolescent
athletes. J Adolesc Health Care 7: 133S–135S, 1986
19. Edwards DJ, Rimmer M, Kenne GC: The use of cold therapy in the
post operative management of patients undergoing arthroscopic
anterior cruciate ligament reconstruction. Am J Sports Med 24:
193–195, 1996
20. Gibbons CER, Solan MC, Ricketts DM, et al: Cryotherapy compared
with Robert Jones bandage after total knee replacement: A prospec-
tive randomized trial. Int Orthop 25: 250–252, 2001
21. Gissane C, Jennings D, Kerr K, et al: A pooled analysis of injury inci-
dence in rugby league football. Sports Med 32: 211–216, 2002
22. Hawkins RD, Hulse MA, Wilkinson C, et al: The association of foot-
ball medical research programme: An audit of injuries in professional
football. Br J Sports Med 35: 43–47, 2001
23. Healy WL, Seidman J, Pfeiffer BA, et al: Cold compressive dressing
after total knee arthroplasty. Clin Orthop 299: 143–146, 1994
24. Herbert RD: How to estimate effects from reports of clinical trials. I:
Continuous outcomes. Aust J Physiother 46: 229–235, 2000
25. Herbert RD: How to estimate effects from reports of clinical trials. II:
Dichotomous outcomes. Aust J Physiother 46: 309–313, 2000
26. Hochberg J: A randomized prospective study to assess the efficacy
of two cold therapy treatments following carpal tunnel release. J
Hand Ther 14: 208–215, 2001
27. Ivey M, Johnston RV, Uchida T: Cryotherapy for postoperative pain
relief following knee arthroplasty. J Arthroplasty 9: 285–290, 1994
28. Johannsen F, Langberg H: The treatment of acute soft tissue trauma
in Danish emergency rooms. Scand J Med Sci Sports 7: 178–181,
1997
29. Kellnet J: Acute soft tissue injuries: A review of the literature. Med Sci
Sports Exerc 18: 489–500, 1986
30. Kerr KM, Daily L, Booth L: Guidelines for the Management of Soft
Tissue (Musculoskeletal) Injury with Protection, Rest, Ice,
Compression and Elevation (PRICE) during the First 64 Hours.
London, Chartered Society of Physiotherapy, 1999
31. Knight KL, Brucker JB, Stoneman PD, et al: Muscle injury manage-
ment with cryotherapy. Athletic Therapy Today 5: 26–30, 2000
32. Knight K: Cryotherapy in sports injury management. Int Perspect
Physiother 4: 163–185, 1989
33. Knight KL: Effects of hypothermia on inflammation and swelling. J
Athletic Train 11: 7–10, 1976
34. Konrath GA, Lock T, Goitz HT, et al: The use of cold therapy after
anterior cruciate ligament reconstruction. Am J Sports Med 24:
629–633, 1996
35. Laba E: Clinical evaluation of ice therapy for acute ankle sprain
injuries. NZ J Physiother 17: 7–9, 1989
36. Lessard LA, Scudds RA, Amendola A, et al: The efficacy of cryother-
apy following arthroscopic knee surgery. J Orthop Sports Phys Ther
26: 14–22, 1997
37. Levy AS, Kelly B, Lintner S, et al: Penetration of cryotherapy in treat-
ment after shoulder arthroscopy. Arthroscopy 13: 461–464, 1997
Vol. 32, No. 1, 2004 Ice for Acute Soft-Tissue Injury 261
38. Levy AS, Marmar E: The role of cold compression dressings in the
postoperative treatment of total knee arthroplasty. Clin Orthop 297:
174–178, 1993
39. MacAuley D: Do textbooks agree on their advice on ice? Clin J Sport
Med 11: 67–64, 2001
40. MacAuley D: Ice therapy: How good is the evidence? Int J Sports
Med 22: 379–384, 2001
41. McClean DA: The use of cold and superficial heat in the treatment of
soft tissue injuries. Br J Sports Med 23: 53–54, 1989
42. McDowell JH, McFarland EG, Nalli BJ: Use of cryotherapy for
orthopaedic patients. Orthop Nurs 13: 21–30, 1994
43. McMaster WC: A literary review on ice therapy in injuries. Am J
Sports Med 5: 124–126, 1977
44. Malone TR, Engelhardt DL, Kirpatrick JS, et al: Nerve injury in ath-
letes caused by cryotherapy. J Athletic Train (Dallas) 27: 235–237,
1992
45. Meeusen R, Lievens P: The use of cryotherapy in sports injuries.
Sports Med 3: 398–414, 1986
46. Merrick MA, Knight KL, Ingersoll CD, et al: The effects of ice and
compression wraps on intramuscular temperatures at various
depths. J Athletic Train 28: 236–245, 1993
47. Michlovitz S, Smith W, Watkins M: Ice and high voltage pulsed stim-
ulation in treatment of acute lateral ankle sprains. J Orthop Sports
Phys Ther 9: 301–304, 1988
48. Moeller JL, Monroe J, McKeag DB: Cryotherapy-induced common
peroneal nerve palsy. Clin J Sport Med 7: 212–216, 1997
49. Moher D, Cook DJ, Eastwood S, et al: Improving the quality of
reports of meta-analyses of randomized controlled trials: The QUO-
RUM statement. Lancet 354: 1896–1900, 1999
50. Moseley A: Evidence for physiotherapy practice: A survey of the
Physiotherapy Evidence Database (PEDro). Aust J Physiother 48:
43–49, 2002
51. Ohkoshi Y, Ohkoshi M, Nagasaki S, et al: The effect of cryotherapy
on intraarticular temperature and postoperative care after anterior
cruciate ligament reconstruction. Am J Sports Med 27: 357–362,
1999
52. Olson JE, Stravino VD: A review of cryotherapy. Phys Ther 52:
840–853, 1964
53. Osbahr DC, Cawley PW, Speer KP: The effect of continuous
cryotherapy on glenohumeral joint and subacromial space tempera-
tures in the postoperative shoulder. Arthroscopy 18: 748–754, 2002
54. O’Toole G, Rayatt S: Frostbite at the gym: A case report of an ice
pack burn. Br J Sports Med 33: 278–279, 1999
55. Rivenberg DW: Physical modalities in the treatment of tendon
injuries. Clin Sports Med 11: 645–659, 1992
56. Sapega AA, Heppenstall B, Sokolow DP, et al: The bioenergetics of
preservation of limbs before replantation. J Bone and Joint Surg 70A:
1500–1513, 1988
57. Scarcella JB, Cohn BT: The effect of cold therapy on the postopera-
tive course of total hip and knee arthroplasty patients. Am J of
Orthop Nov: 847–852, 1997
58. Schroder D, Passler HH: Combination of cold and compression after
knee surgery: A prospective randomized study. Knee Surg Sports
Traumatol Arthrosc 2: 158–165, 1994
59. Sloan JP, Hain R, Pownall R: Clinical benefits of early cold therapy in
accident and emergency following ankle sprain. Arch Emerg Med 6:
1–6, 1989
60. Swenson C, Sward L, Karlsson J: Cryotherapy in sports medicine.
Scand J Med Sci Sports 6: 193–200, 1996
61. Thorsson O: Cold therapy of athletic injuries: A literature review.
Lakartidningen 98: 1512–1513, 2001
62. Verhagen AP, de Vet HCW, de Bie RA, et al: The Delphi List: A crite-
ria list for quality assessment of randomized clinical trials for con-
ducting systematic reviews developed by Delphi consensus. J Clin
Epidemiol 51: 1235–1241, 1998
63. Whitelaw GP, DeMuth KA, Demos HA, et al: The use of cryocuff ver-
sus ice and elastic wrap in postoperative care of knee arthroscopy
patients. Am J Knee Surg 8: 28–31, 1995
64. Wilkerson GB, Horn-Kingery HM: Treatment of the inversion ankle
sprain: Comparison of different modes of compression and cryother-
apy. J Orthop Sports Phys Ther 17: 240–246, 1993
65. Zemke JE, Anderson JC, Guion WK, et al: Intramuscular temperature
responses in the human leg to two forms of cryotherapy: Ice mas-
sage and ice bag. J Orthop Sports Phys Ther 27: 301–307, 1998
... The ice pack application is a common treatment for medial ligament injuries. The ice pack helps reduce the swelling and inflammation around the injured ligament (Bleakley C, McDonough S & MacAuley D., 2004). It is important to apply the ice pack for the recommended time to reduce swelling. ...
... Surgery is typically the only way to repair a medial ligament injury. The surgeon will make an incision in the knee and then insert a graft to replace the damaged ligament (Bleakley C, McDonough S & MacAuley D., 2004). The surgery usually takes about an hour to complete and is likely to need to stay in the hospital for a few days afterwards. ...
... Stefanelli et al. (2019) found that DOMS reduced corticospinal excitability and after the administration of menthol-based topical analgesic, there was a reduction in pain, which was accompanied by increased corticospinal inhibition. Although ice application is considered the traditional method for post-exercise pain relief, Johar et al. (2012) demonstrated that compared to ice, the topical menthol-based analgesic decreased perceived discomfort to a greater extent and permitted greater tetanic forces to be produced, and the effectiveness of ice for acute injury has not been proven in any clinical trials and may even be harmful (Bleakley et al., 2004). Airaksinen et al. (2003) showed that topical menthol gels not only provide excellent pain relief, but also promote recovery in patients with exercise-related soft tissue injuries. ...
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Menthol is an important flavoring additive that triggers a cooling sensation. Under physiological condition, low to moderate concentrations of menthol activate transient receptor potential cation channel subfamily M member 8 (TRPM8) in the primary nociceptors, such as dorsal root ganglion (DRG) and trigeminal ganglion, generating a cooling sensation, whereas menthol at higher concentration could induce cold allodynia, and cold hyperalgesia mediated by TRPM8 sensitization. In addition, the paradoxical irritating properties of high concentrations of menthol is associated with its activation of transient receptor potential cation channel subfamily A member 1 (TRPA1). Under pathological situation, menthol activates TRPM8 to attenuate mechanical allodynia and thermal hyperalgesia following nerve injury or chemical stimuli. Recent reports have recapitulated the requirement of central group II/III metabotropic glutamate receptors (mGluR) with endogenous κ-opioid signaling pathways for menthol analgesia. Additionally, blockage of sodium channels and calcium influx is a determinant step after menthol exposure, suggesting the possibility of menthol for pain management. In this review, we will also discuss and summarize the advances in menthol-related drugs for pathological pain treatment in clinical trials, especially in neuropathic pain, musculoskeletal pain, cancer pain and postoperative pain, with the aim to find the promising therapeutic candidates for the resolution of pain to better manage patients with pain in clinics.
... With such a wide range of cryo protocols, the total treatment time subjects received was extremely variable. It is not possible to provide instructions for when to use cryo because it is dependent on the characteristics of each device (15). ...
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Worldwide, lymphedema can present as a significant health issue. Left untreated, it can have long-term medical and psychological consequences for patients. Cryotherapy is a new physical therapy modality used for many purposes including reduction of pain, inflammation, and edema. It is thought to decrease interstitial fluid volume through many mechanisms. Therefore, it is reasonable to think that cryotherapy might have a positive effect in treatment of lymphedema. The goal of this study was to investigate how local cryotherapy in combination with standard therapy affects patient outcomes. Forty post-mastectomy female patients aged 40-60 years old with lymphedema were referred to the outpatient clinics of the Faculty of Physical Therapy at South Valley University for medical treatment and follow-up by the vascular surgery department. Patients were randomly divided into two groups of equal size. Traditional physical therapy programs (manual lymphatic drainage, pneumatic compression, bandaging, breathing exercises, circulatory exercises, shoulder mobilizations, and ROM exercises) were combined with pulsed local cryotherapy three times per week for 12 weeks in Group (A). For 12 weeks, Group (B) received only traditional physical therapy three times per week. Patients were evaluated using circumferential measurement with tape at the wrist, below the elbow, and above the elbow level, as well as ultrasonography to assess skin thickness before the start of physical therapy, 6 weeks later, and at the end of the treatment (after 12 weeks). Results indicate that cryotherapy is an effective adjunct modality for the treatment of secondary lymphedema and should be added to physical therapy protocols for lymphedema rehabilitation.
... To facilitate the restoration process, therapeutic interventions are applied to damaged skeletal muscles (Freitas et al. 2007;Jarvinen et al. 2007;Li et al. 2010;Oyaizu et al. 2018;Kawashima et al. 2021a, b). Among these interventions, icing has traditionally been used as one of the acute treatments to inhibit the inflammatory response, including pain and swelling, following soft-tissue injury (Swenson et al. 1996;Bleakley et al. 2004). However, several studies using animal models have reported that icing after skeletal muscle injury impairs muscle regeneration (Takagi et al. 2011;Shibaguchi et al. 2016;Kawashima et al. 2021a, b). ...
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Following skeletal muscle injury, both myogenic and immune cells interact closely during the regenerative process. Although icing is still a common acute treatment for sports-related skeletal muscle injuries, icing after muscle injury has been shown to disrupt macrophage accumulation and impair muscle regeneration in animal models. However, it remains unknown whether icing shortly after injury affects macrophage-related phenomena during the early stages of muscle regeneration. Therefore, we focused on the distribution of M1/M2 macrophages and cytokines expressed predominantly by macrophages during the early stages of muscle regeneration after muscle crush injury. Icing resulted in a decrease, not retardation, in the accumulation of M1 macrophages, but not M2 macrophages, in injured muscles. Consistent with the decrease in M1 macrophage accumulation, icing led to a reduction, instead of delay, in the level of tumor necrosis factor-α (TNF-α) expression. Additionally, at subsequent timepoints, icing decreased the number of myogenic precursor cells in the regenerating area and the size of centrally nucleated regenerating myofibers. Together, our findings suggest that icing after acute muscle damage by crushing disturbs muscle regeneration through hindering tM1 macrophage-related phenomena.
... This therapy has been frequently applied for pain management and postoperative care for sports injuries and surgical procedures and has been effective in reducing edema and recovery time, with short-term applications in abdominal, orthopedic, and gynecological operations [15][16][17][18][19]. Basically, low temperatures cause vasoconstriction, and pain reduction is achieved because the temperature blocks nerve endings [11]. This analgesic effect is the combination of slower propagation of neural pain signals and decreased release of chemical pain mediators, which also triggers a decrease in metabolism by more than 50%, allowing better oxygen flow to the injured tissues [20]. ...
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Chapter
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The aim of this study was to evaluate the analgesic effect of an external cooling system with or without the combined effect of intra-articularly administered bupivacaine/morphine after arthroscopic anterior cruciate ligament (ACL) reconstruction. Fifty patients with isolated ACL insufficiency operated on under general anaesthesia were randomized to three different postoperative treatment groups. Group I was treated with the cooling system during the first 24 h after surgery and an intraarticular injection of 20 ml of physiological saline given at the completion of surgery; in group II, the cooling system was combined with an intra-articular injection of 20 ml bupivacaine 3.75 mg/ml and 1 mg of morphine at the end of the operation; while group III (placebo group) received an intra-articular injection of 20 ml of physiological saline at the completion of surgery. Pain was assessed using a visual analogue scale (VAS) at 1, 2, 4, 6, 24 and 48 h postoperatively. Supplementary analgesic requirements were registered. In group I 80% (16/20) and in group II 90% (18/20) of the patients were satisfied with the postoperative pain control regimen (NS). This was significantly better than in group III, where 30% (3/10) were satisfied. The pain scores were significantly lower in the two treatment groups compared with the placebo group during the entire postoperative period. The pain score was significantly lower in group II than in group I at 24 and 48 h after surgery. The supplementary analgesic requirements were also lower in the two treatment groups compared with the placebo group. No complications due to the use of the cooling system or the intra-articular injections of bupivacaine/morphine were observed. The external cooling system used in this study provides an effective method of obtaining pain relief after arthroscopic surgery. The combination with an intra-articular injection of morphine and bupivacaine results in a slightly greater analgesic effect than the cooling system alone.