The following research article summaries provide evidence in support of cold packs and/or cryotherapy as a modality used in physical therapy:
Cold packs of all types work to control inflammation and create a numbing feeling to allow for therapeutic exercises by lowering the tissue temperature. Merrick et al. compares the efficacy of different types of cryotherapy including bags of crushed ice, commercially available ice packs, and commercially available frozen gel packs in their article, Cold Modalities with Different Thermodynamic Properties Produce Different Surface and Intramuscular Temperatures. They found that the two forms that undergo phase changes during treatment time, the crushed ice bag and commercial ice pack, create lower surface tissue temperature and 1 cm intramuscular temperature than the frozen gel pack that does not change phases. This happens via the heat transfer that occurs during conduction. No major temperature difference was found between types for 2 cm sub-adipose depth. Overall, this article supports the use of all three types of cold packs in lowering tissue temperature for controlling inflammation.
This article reviewed other articles regarding clinical evidence for the use of cryotherapy. Does the application of ice help to improve treatment outcomes? In order for a study to qualify in the review, the study had to meet many conditions/qualifications. The PEDro scale was used to rate the articles for method quality. The PEDro scale is an 11 item checklist that examines the interpretability and believability (internal validity) of trial quality. If all criteria are satisfied on the PEDro scale, a maximum score of 10 can be achieved. The average score on the PEDro scale for the articles reviewed was 3.4. 55 articles were reviewed, and 22 were eligible randomised, controlled trials of human subjects. The studies included an average of 66.7 subjects and types of injuries varied widely. Other items that varied were mode of cryotherapy, duration and frequency of cryotherapy application, and the time period in which the cryotherapy was applied. Overall, a total of 12 treatment comparisons were made. In regards to swelling, pain, and range of motion, ice is reported to be no different than ice with electric stimulation. However, application of ice does seem to be more effective than no use of cryotherapy after minor knee injury in regards to pain. A significantly greater decrease in pain with the use of continuous cryotherapy is noted as opposed to intermittent cryotherapy. There is minimal evidence to suggest that a single treatment of ice and compression is no more effective than no cryotherapy after an ankle sprain injury. In regards to pain, swelling, and range of motion, ice is reported to be no more effective than rehabilitation. Also, in terms of decreasing pain, ice used in conjunction with compression seems to be significantly more effective than just the use of ice. Lastly, when reviewing 8 of the studies, there is little difference in the effectiveness of ice and compression compared to the use of compression by itself. Overall, cryotherapy seems to be an effective intervention in decreasing pain. However, the efficiency of cryotherapy has been questioned in comparison to other rehabilitation techniques. More studies are required on the use of cryotherapy to establish evidence and efficacy of cryotherapy.
This study reviewed the use of hot and cold packs on pain management and temperature changes through multiple cutaneous levels. 16 male and female volunteers (average age 25.4) with no documented health conditions were chosen for the study. The muscle group tested were the quadriceps at 1, 2 and 3 cm of depth. Measurements were taken before, during and after 20 minutes of cryotherapy. Results indicated an overall rise in temperature during the first 5 minutes followed by a drop in temperature at 8 minutes between the epidermis and 1 cm depth. No significant change was acknowledged at depths of 2 or 3 cm. However, as superficial level temperatures began to rise the deeper levels (2 and 3 cm) began to drop simultaneously to an extent of 40 minutes. The researchers concluded that cold pack therapy produces an overall significant drop in cutaneous temperatures allowing for a hemodynamic change. This offers an “explanation for the reduction of pain, muscle spasm, and edema…” which leads me to believe that therapy such as TherEx could be more easily achieved should pain, muscle spasm, or edema be the cause for lack of treatment.
References are in order of appearance
Merrick, M. A., Jutte, L. S., & Smith, M. E. (2003). Cold Modalities With Different Thermodynamic Properties Produce Different Surface and Intramuscular Temperatures. Journal of athletic training, 38(1), 28-33. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=155508&tool=pmcentrez&rendertype=abstract
Hubbard, T. J., Denegar, C. R. (2004). Does Cryotherapy Improve Outcomes With Soft Tissue Injury? Journal of Athletic Training, 39(3), 278-279. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC522152/?tool=pubmed
Enwemeka, C. S., Allen, C., Avila, P., Bina, J., Konrade, J., & Munns, S. (2002). Soft tissue thermodynamics before, during, and after cold pack therapy. Medicine and science in sports and exercise, 34(1), 45-50. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11782646
The following research article summaries provide evidence not in support of or show lack of evidence for cold packs and/or cryotherapy as a modality used in physical therapy:
Although cold packs are widely used and do help in some patients, for others, cold packs may be insignificant. The effect of cold therapy on pain, swelling, and range of motion after anterior cruciate ligament reconstructive surgery, by Daniel et al, describes how cold therapy of various temperatures made no impact on several factors including hospital stay, pain medication use, pain scale, knee girth, or range of motion. This study used cooling pads of various temperatures of 40, 45, 55, and 70 degree in the dressings of 89 total post-operation ACL patients and no cooling pads in 42 other patients. In this, there were no statistically significant differences between any of the groups, thus refuting the use of cold packs for this particular injury.
The application of ice is a widely accepted clinical practice in the treatment of ankle sprain even though the evidence supporting the use of cryotherapy as a treatment intervention of acute soft tissue injury is generally poor. Evidence is lacking in regards to optimal mode, duration, or frequency of ice application. The objective of this study is to compare intermittent cryotherapy treatment protocol with standard cryotherapy treatment protocol in managing acute ankle sprains. Eighty nine subjects were involved, 58 males and 31 females, with a mean age of 29.9. To qualify for the study, subjects must have sustained a mild/moderate ankle sprain within the preceding 48 hours. Having a positive anterior drawer test and talar tilt test excluded subjects from the trial. Subjects were assigned to either standard or intermittent treatment. There were 46 standard participants and 43 intermittent participants. Standard ice application included 20 minutes of continuous ice every two hours for the first 72 hours of injury. Intermittent ice application included 10 minutes of ice, removing ice for 10 minutes, and then reapplying ice for another 10 minutes. This too was performed every two hours for the first 72 hours of injury. Treatment was self administered and subjects were encouraged to perform ankle mobility exercises once a day for the first week. Subjects function, pain, and swelling measurements were recorded initially and then at one, two, three, four, and six weeks after injury. Results showed both standard and intermittent groups having significant improvements over time in pain, function, and swelling. There was one significant difference between the two groups, subjects in the intermittent ice application group reported less pain during everyday activity at week 1 than the standard ice application group. In conclusion, intermittent ice application helps pain relief in the early stages of rehabilitation of acute soft tissue injury and may enhance the therapeutic effect of ice after these types of injuries.
The purpose of this study was to assess the effect of superficial thermo/cryotherapy on lower back pain. A Cochrane review of nine trials totaling 1,117 patients experiencing acute or sub-acute low back pain was performed. The group concluded that the evidence for common practice of heat or cold treatment for acute and/or sub-acute lower back pain was limited. There was a moderate amount of evidence to support the modality of heat as a short-term pain reducer, but evidence to support cold therapy was insufficient or inconclusive when differentiating whether cold or heat was more beneficial.
References are in order of appearance
Daniel, D. M., Stone, M. L., & Arendt, D. L. (1994). The effect of cold therapy on pain, swelling, and range of motion after anterior cruciate ligament reconstructive surgery. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 10(5), 530-3. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/7999161
Bleakley, C. M., McDonough, S. M., MacAuley, D. C. (2006). Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. British Journal of Sports Medicine, 40, 700-705. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579462/?tool=pubmed
French, S. D., Cameron, M., Walker, B. F., Reggars, J. W., & Esterman, A. J. (2006). A Cochrane review of superficial heat or cold for low back pain. Spine, 31(9), 998. doi:10.1097/01.brs.0000214881.10814.64
Summaries provided by Zac Snow, Brittany Brown, and Lauren Mulsow
Commercial Cold Packs
ReplyDeleteThe following research article provides support for the use of commercial cold packs on patients following total knee arthroplasty.
Comparison of gaseous cryotherapy with more traditional forms of cryotherapy following total knee arthroplasty.
The use of cryotherapy for various injuries has been around for centuries and is nothing new to the physical therapy field. However, some research shows that cold packs/cryotherapy may not be as beneficial to the patient as we once thought. This article compared gaseous cryotherapy following total knee arthroplasty (TKA) with more traditional forms or cold therapy such as cryo-cuff and commercial cold packs.
This particular study was conducted in Liege, Belgium by Demoulin et al. The study consisted of 66 patients that received a unilateral total knee arthroplasty and received three different forms of treatment in regards to cryotherapy post surgery. The first group received gaseous cryotherapy (GC). This particular device consisted of a spray nozzle that was powered by a CO2 canister and provided a dry cooling effect to the skin. It was administered for 90 seconds three times a day for to the patient. The second group was given a traditional “gel” cold pack. This was applied over a towel to prevent frostbite and was wrapped on the individual for or 20 minutes 5 times a day. The last group was given a traditional cryo-cuff that encompassed the entire knee and provided cold-water circulation. This was applied to the knee for 20 minutes 5 times a day.
The results from this study showed that cryotherapy was beneficial for decreasing pain and inflammation, which supports previous studies. However, a control group was not included due to the fact the cryotherapy is seen as the best plan of care in patients post TKA. No difference between groups was observed regarding the clinical outcomes. Further studies with larger sample size and with a more frequent and closer gaseous cryotherapy applications are needed to confirm that gaseous cryotherapy is not more beneficial than more traditional cold applications following TKA. This supports the use of commercial cold packs for acute injuries to reduce pain and inflammation.
Demoulin C. Comparison of gaseous cryotherapy with more traditional forms of cryotherapy following total knee arthroplasty. Annals of physical and rehabilitation medicine. 2012-05;55:229-40.
submission from T. Reed and Molly B.
Phys Ther Sport. 2012 Nov;13(4):265-9. doi: 10.1016/j.ptsp.2012.02.001. Epub 2012 Apr 23.
ReplyDeleteAcute effects of cold pack on mechanical properties of the quadriceps muscle in healthy subjects.Mustalampi S, Ylinen J, Kautiainen H, Weir A, Häkkinen A.Source Department of Physical Medicine and Rehabilitation, Jyvaskyla Central Hospital, Keskussairaalantie 19, 40620 Jyvaskyla, Finland. sirpa.mustalampi@ksshp.fi
The following article refutes the use of cold pack therapy for individuals immediately returning to strenuous activity.
Cryotherapy is commonly used as a treatment for acute and chronic injuries for pain reduction, edema reduction and inflammation control. However there are some circumstances where cold therapy may not be indicated as the best course of action. Studies have shown that local cooling produces significant temperature falls in superficial tissues and gradual decrease in deep tissue temperature before a slow recovery. Previous studies have also shown that cooling has been shown to decrease responsiveness of the contractile system and increase resistance to movement. This study by Mustalampi et al. sought out to demonstrate the effects of cooling on mechanical properties of the quadriceps muscle in healthy subjects immediately and after a 15-min recovery.
There were 39 healthy subjects recruited for this study with a mean age of 39. Muscle tension, elasticity, and stiffness were determined with a Myoton-3 instrument which detects mechanical responses of the muscle through an acceleration probe. Muscle compliance was measured with a Computerized Muscle Tonometer which quantifies the amount of tissue displacement per unit force applied by a probe as it is pressed into the tissue. The temperatures of skin, cold pack, and the testing room were measured with the Fluke 52 II Thermometer and the thickness of the skin, subcutaneous fat, rectus femoris, and vastus intermedius muscles were measured by ultrasound. Patients were placed in supine with hips and knees extended and feet and ankles strapped together. Baseline measurements of the quadriceps muscles were taken and then a cold gel pack with a mean temperature of 0.3 degrees Celsius wrapped in one layer of a dry towel was applied.
Results of the study showed that after 20 minutes of cooling the quadriceps muscle became tenser, stiffer, and less elastic and that after 15 minutes of cryotherapy removal, the mechanical properties of the tissue and skin temperature were not fully recovered. The increased muscle tension and intramuscular pressure can result in decreased blood circulation which can cause weakness, fatigue and pain during movement. The increased muscle stiffness results in more energy required to modify the shape of the muscle and studies have shown that this can cause damage to the muscle. It was also found in this study that after the cryotherapy treatment there was a higher amount of energy being dissipated during a single oscillation period which resulted in the assumption that cooling decreases a muscle’s capacity to store energy resulting in decreased power. In conclusion, it takes greater than 15 minutes for muscular tissue to fully recover following cryotherapy treatment. The muscle will have decreased power and functional performance due to the mechanical property changes. Therefore in the incidence of need for immediate return to sport, it is not recommended that cryotherapy by implemented as a careful warm-up and ample time should be taken before performing strenuous activities to avoid further soft tissue damage.
Submission from T. Reed and Molly B.
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