Therapeutic Ultrasound

Our group didn't have a lot of trouble finding research articles about therapeutic ultrasound, however the difficulty came when trying to find good articles that provided sound support for its effectiveness or uneffectiveness. We have summarized articles that support, refute, and are undetermined whether ultrasound is an effective form of treatment for both acute and chronic conditions.   

From the time that ultrasound’s interaction with living tissue was first investigated, biological effects have been recognized. These include enhanced blood flow, membrane permeability, connective tissue extensibility and nerve conduction. The effectiveness of ultrasound is still unproven, however the study “Is therapeutic ultrasound effective in treating soft tissue lesions” is attempting to prove that it is, in fact, effective. In this study 76 patients with lateral epicondylitis were treated with an ultrasound used for routine therapy.  Part of the patients were treated with a placebo  ultrasound. The findings of the study showed that ultrasound enhanced recovery in patients with lateral epicondylitis, but only in 63% of the time. By evaluating the data it was shown that the rate of recovery was better in the patients treated with active ultrasound. There was also a decreased incidence of recurrence in the patients treated with active ultrasound.

Ortas, Turan, Bora and Karakaya (1998) looked at the effectiveness of ultrasound on carpal tunnel syndrome.  The results showed that there was a significant decrease in pain and symptoms in the two group with ultrasound (1.5 w/cm2, 0.8 w/cm2), however there was also a decrease in the placebo group (no ultrasound).  The author makes the argument that the role of placebo affect should be considered and is a “well-recognized phenomena". Nerve conduction was also seen to have decreased in the groups with ultrasound, whereas the group with placebo ultrasound did not.

In the article, “Ultrasound treatment for treating the carpal tunnel syndrome: randomized “sham” controlled trial,” Ebenbichler et. al. divided the subjects of the study randomly into two groups: treatment group receiving ultrasound, and a “sham” (control) group receiving indistinguishable sham ultrasound treatment for treatment of the patients carpal tunnel syndrome.  The treatment group received 20 sessions of ultrasound at 1 MHz. 1.0 W/cm², pulsed mode for 15 minutes a session.  After completion of the sessions, and study, the authors stated that their results show there is evidence that ultrasound treatment is beneficial for short and medium relief of carpal tunnel syndrome.   

In a study done by Robertson and Baker, these trials were designed to investigate how active ultrasound works in comparison to a placebo ultrasound. In 8 out of 10 trials reviewed, there were no significant differences found between the active and placebo ultrasound. Each of the 8 studies were designed by different researchers in different labs and found almost identical outcomes. There is also limited data to back dosaging.  The limits of these studies lie in the fact that they were all RCTs. There are other ways to obtain information on ultrasound. Many clinicians have found that ultrasound does have a positive effect on their patients. However, with no experimental data showing a significant difference between active and placebo ultrasound, there is no justifications for using ultrasound clinically. A valid criticism of this study is that it took information from 10 different RCT studies. Each study had imprecise details that may have changed the outcome of the studies. However, when all of the flawed studies were excluded there were very few RCTs that studied ultrasound.

This study proves that there is more investigation needed to find the true clinical effectiveness of ultrasound. With the information available at the time of this study there was not enough significant evidence to support the clinical use of ultrasound. 

The article “How effective is therapeutic ultrasound in the treatment of heel pain?” by Crawford and Smith used two groups to treat heel pain; one treatment group using ultrasound, and one control group that received a placebo ultrasound treatment.  The ultrasound machine was calibrated to 3MHz, 0.5 W/cm², using a pulsed setting for the treatment group.  After the treatments the authors concluded that using ultrasound was no more effective than the control group.  The authors believed this because the placebo group received feedback as the “treatment” helped the patients, as did the true treatment group. 

In the article “Physiotherapy for patients with soft tissue shoulder disorders” evidence was shown that ultrasound was ineffective as a treatment, however, they did go to great lengths to discuss the “unsatisfactory” methods that were used to come to this conclusion.  The article was a systemic computerized literature search and the researchers were looking for information about physiotherapy for soft tissue shoulder injuries.  Ultrasound appeared to be their primary target, although there was some discussion about cold therapy, steroid injections, electrical stimulation, low laser therapy and exercise.  Some things that they thought led to poor data were varied parameters for ultrasound application (intensity, duration, frequency),  the compared treatment was poor or inadequate, poor population selection and follow up.  The biggest thing I learned from this article wasn’t that ultrasound with ineffective, it was that we need to make sure that our research is sound research.

References:

Binder, A. (1985). is therapeutic ultrasound effective in treating soft tissue lesions. Retrieved from http://www.bmj.com/highwire/filestream/244698/field_highwire_article_pdf/0.pdf

Crawford, F., & Smith, M. (1996). How effective is theraputic ultrasound int he treatment of heel pain? Annals of the Rheumatic Diseases, 265-267.

Ebenbichler, G. R., Resch, K. L., Nicolakis, P., Wiesinger, G. F., Uhl, F., Ghanem, A.-H., et al. (1998). Ultrasound treatment for treating the capral tunnel syndrome: randomized "sham" controlled trial. British Medical Journal, 731-735.

Oztas, O., Turan, B., Bora, I., & Karakaya, M. K. (1998). Ultrasound therapy effect in carpal tunnel syndrome. Archives of physical medicine and rehabilitation, 79(12), 1540-4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9862296

Robertson, V. (2001). A review of therapeutic ultrasound: Effectiveness studies. Journal of the American Physical Therapy Association, 81(7), 1339-1350. Retrieved from http://physther.net/content/81/7/1339.short

van der Heijden, G. J. M. G., van der Windt, D. A. W. M., & de Winter, A. F. (1997). Physiotherapy for patients with soft tissue shoulder disorders: a systematic review of randomised clinical trials. BMJ, 315(7099), 25-30. doi:10.1136/bmj.315.7099.25

Katie B., Amanda L., Michael D.

Massage and Delayed Onset Muscle Soreness

Delayed onset muscle soreness (DOMS) refers to the muscle pain and soreness that occurs with exercise-induced damage after eccentric exercise.  It peaks about 24-48 hours after exercise and subsides over the following 5-9 days.  Massage has been proposed as a therapeutic technique to prevent DOMS, however the literature findings both advocate and refute it as an effective means of preventing or treating DOMS.

           

Hilbert, Sforzo, and Swensen found massage to be an effective technique to treat DOMS.   They evaluated both physical and psychological aspects using the Differential Descriptor Scale (DDS), Profile of Mood States (POMS), and a blood test for neutrophils.   Researchers compared 20-minute massage intervention to no massage after isokinetic eccentric contraction exercises in the right hamstrings.   Massage was given 2 hours after exercise.  The DDS, POMS, and a blood test were completed 6, 24, and 48 hours post-exercise.  They found massage intervention to lessen the intensity of soreness reported 48 post-exercise; however, it had no effect on neutrophils.  (Hilbert, Sforzo, & Swenson, 2003)

Smith LL, Keating, Holbert, Spratt, McCammon, Smith SS, and Israel found that applying a sport massage to muscles two hours after eccentric exercise does in fact reduce the effects of DOMS and the levels of serum creatine kinase (CK) in the muscles. They randomly assigned seven males each to a massage group and control group. Two hours after doing five sets of isokinetic eccentric bicep exercises working the elbow flexors and extensors, the massage group received a thirty-minute sport massage while the control group rested.  Levels of DOMS and CK were tested before the exercise, and 8, 24, 48, 72, 96, and 120 hours post-exercise. Circulating neutrophils and cortisol levels were tested before and right after the exercise, and every thirty minutes for the following eight hours. Both DOMS and CK showed reduced levels for the massage subjects.  Further, the level of neutrophils showed a prolonged elevation and cortisol showed diminished diurnal reduction.  (Smith, Keating, Holbert, Spratt, McCammon, Smith, & Israel, 1994).

Mancinelli, Davis, Aboulhosn, Brady, Eisenhofer, and Foutty found that massage effectively decreased the effects of DOMS in women collegiate athletes. Researchers evaluated perceived soreness using a 10-point visual analog scale. The experimental group received 17 minute massages immediately following practice on the fourth day of pre-season training while a control group rested for 17 minutes. Researchers used the 10-point visual analog scale to measure perceived soreness immediately following the massages and rest period. They found that the massages significantly reduced the level of perceived soreness, while no change in perceived soreness was seen in the control group. (Mancinelli et al., 2005)

Zainuddin, Newton, Sacco, and Nosaka found no significant difference in an arm-to-arm study between massage treatment and no treatment on the effects of DOMS.  They compared arms of the same subjects after an exercise routine, treating one arm to a 10-minute sports massage 3 hours after exercise and leaving the other as a control.  Soreness was rated on a 100 mm visual analog scale during flexion, extension, and palpation on days 1,2,3,4,7,10, and 14 post-exercise.  Muscle damage was induced by isokinetic eccentric maximal contractions of the biceps muscles of both left and right arms.  (Zainuddin, Newton, Sacco, & Nosaka, n.d.)

Jonhagen, Ackermann, Eriksson, Saartok, and Renstrom hypothesized sports massage would improve muscle recovery after eccentric exercise. They performed a randomized clinical trial with sixteen subjects who each did 300 maximal eccentric contractions with both right and left quadriceps. Each subject received a sport massage on only one leg once a day for three days after the exercise. Their other leg acted as a control and did not receive massage. Three tests were done on each leg, once a day for three days. They tested one-leg long jumps, maximal strength using a Kin-Com dynamometer, and evaluated pain by using a visual analog scale.  They found the sport massage did not affect the amount or duration of pain. It also did not affect the strength or function of the muscle after exercise. (Jonhagen, Ackermann, Eriksson, Saartok, & Renstrom, 2004)

Hart, Swanik, and Tierney found massage to be ineffective in decreasing the effects of delayed onset muscle soreness. Subjects were put through a series of eccentric leg exercises. Twenty-four, 48, and 72 hours after the exercise regimen, subjects returned to the lab where they received a five-minute sport massage on one leg while the other leg only rested. Pain measurements were assessed after each massage treatment with a visual analog scale with two extremes: no pain and worst possible pain. Researchers found no difference in relief from DOMS between the leg that was massaged and the leg that only rested. (Hart, Swanik & Tierney, 2005)

Based on the current literature, massage can be an effective method of treating DOMS for some, and have no significant difference in others.  The use of massage should be the decision of the clinician based on each individual client and their response to treatment.  More research needs to be conducted in order to come to a conclusion about how DOMS responds to massage.

Summaries by Brianna, Natalie, and Sarah L.

References

Hart, J. M., Swanik, C. B., & Tierney, R. T. (2005). Effects of sport massage on limb girth and discomfort associated with eccentric exercise. Journal of athletic training, 40(3), 181-5. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1250257&tool=pmcentrez&rendertype=abstract

Hilbert, J. E., Sforzo, G. A., & Swenson, T. (2003). The effects of massage on delayed onset muscle soreness. British Journal of Sports Medicine, 37(1), 72-75. BMJ Publishing Group Ltd and British Association of Sport and Exercise Medicine. doi:10.1136/bjsm.37.1.72

Jonhagen, Sven, Paul Ackermann, Tommy Eriksson, Tonu Saartok, and Per A. F. H. Renstrom. "Sports Massage After Eccentric Exercise." The American Journal of Sports Medicine 32.6 (2004): 1499503. SAGE. Web. 22 Jan. 2012. <http://ajs.sagepub.com/content/32/6/1499.short>

Mancinelli, C. A., Davis, D. S., Aboulhosn, L., Brady, M., & Eisenhofer, J., Foutty, S. (2006). The effects of massage on delayed onset muscle soreness and physical performance in female collegiate athletes. Physical therapy in sport, 7(1), 5-13.

 Smith, L. L., M. N. Keating, D. Holbert, D. J. Spratt, M. R. McCammon, S. S. Smith, and R.             G. Israel. "The Effects of Athletic Massage on Delayed Onset Muscle Soreness, Creatine Kinase, and Neutrophil Count: A Preliminary Report." The Journal of Orthopaedic and Sports Physical Therapy 19.2 (1994): 93-9. UK Pubmed Central. Web. 22 Jan. 2012. <http://ukpmc.ac.uk/abstract/MED/8148868>

Zainuddin, Z., Newton, M., Sacco, P., & Nosaka, K. (n.d.). Effects of massage on delayed-onset muscle soreness, swelling, and recovery of muscle function. Journal of athletic training, 40(3), 174-80. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1250256&tool=pmcentrez&rendertype=abstract

Cold Whirlpool and Ankle Sprains

Kylie Palermo, Kate Wiens, Rick Hill

Searching for evidence on cold whirlpools and ankle sprains was difficult. There was very little research on the subject and whirlpool treatment in general. In order to fully understand the effect a cold whirlpool treatment will have on a sprained ankle, more research must be conducted.

Articles in support of cold whirlpool

An article I found in favor of cold whirlpool treatment for the treating of ankle injury was a narrative review (“The physiological basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner.” PMID: 16858479). This article discussed a study that showed that cold whirlpool resulted in a greater decrease in swelling than an ice pack did. The study stated cold whirlpool was more effective both one day and four days into treatment.

One article I found in favor of using a cold whirlpool treatment for treating ankle sprains was a study that compared using a cold whirlpool to an ice pack (“Temperature changes in the human leg during and after two methods of cryotherapy.” PMID: 16558480)  To interpret this article as providing support, you have to already be on board with using cryotherapy of some kind as a modality to treat ankle sprains. Given that, this study found that a cold whirlpool was better than an ice pack in producing sustained temperature declines in tissue, which would give a therapist more time to work with a patient after applying the modality.

The article: “Comparison of three treatment procedures for minimizing ankle sprain swelling” Physical Therapy July 1988 vol. 68 no. 7 1072-1076 concluded that cold immersion therapy is a better option than heat or contrast baths. It should be noted that with all 3 treatment modalities, there was still an increase in edema. However, cryotherapy is the best option for minimizing edema before exercising.

Articles against cold whirlpools

The article: “Localized whirlpool folliculitis in a football player.” Cutis. 2000 Jun;65(6):359-62 PMID:10879303 described the poor sanitation of whirlpools. Pseudomonas aeruginosa folliculitis is an infection associated with whirlpools. Coaches and trainers should use new water for each player and washing the foot prior to the tub. In reality, these precautions are not very feasible due to time constraints, resources, and the size of a football team. In conclusion, whirlpools are not the best cryotherapy modality due to the high presence of bacteria.

An article that suggests cold whirlpool treatment would not be good for the treatment of ankle injuries discusses the gravity-dependent position (“Volume decreases after elevation and intermittent compression of post acute ankle sprains are negated by gravity-dependent positioning.” PMID: 14737214). This article discussed both previous experiments and the performed experiment. Although it stated the effects of elevation may not be sustainable for a long period of time, it had multiple resources stating that a gravity-dependent position will inhibit a reduction in lower extremity swelling. This suggests that the gravity-dependent position of a cold whirlpool for an ankle sprain would be counterproductive. Instead, a form of cryotherapy combined with elevation would be more effective in reducing swelling.

One article I found against using a cold whirlpool treatment for treating ankle sprains was a systematic review (“Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence” http://bmb.oxfordjournals.org.proxy.kumc.edu:2048/content/97/1/105.full) which didn’t mention cold whirlpools, or cryotherapy of any kind, at all. This could suggest that when it comes to best practices, there isn’t any evidence to support the use of cryotherapy generally, or cold whirlpools in particular, to manage ankle sprains.

Paraffin Bath and Rheumatoid Arthritis

Introduction:

Paraffin baths are a form of thermotherapy that is used mainly on the hands and feet. The paraffin is a superficial heater and allows a depth of 1 cm of therapeutic heating. It is used for therapy because it has the therapeutic effects of decreasing pain and increasing soft-tissue extensibility. Paraffin baths can be used for treatment of rheumatoid arthritis (RA). There have been studies done to see if paraffin baths are an effective form of therapy for and should be used in the clinics. 

Research supporting use of paraffin bath:

In a review by Marks and Ayling (1995) on the effect of paraffin baths on treatment for RA, it was found that paraffin baths can be an effective treatment. They started by searching for studies on the CINHAL, MEDLINE, and EMBASE databases. The terms that were searched were rheumatoid arthritis, therapeutic use of heat, and therapeutic use of cold. There was also a manual search that was done to help locate additional literature that could be used. The studies found had to have the focus of the effect of paraffin was on the temperature of hand joints or the application of paraffin wax and its effect on RA. Clinical trials examining the effect paraffin wax has on hand tissue temperature, randomized controlled clinical trials examining the use of paraffin wax for treating RA, and basic studies were thoroughly assessed according to standardized criteria. Four randomized studies were found that met the search criteria. Three of the four studies found that after three to four weeks, the use of paraffin baths coincided with significant improvements in hand function for subjects with RA when exercised followed the paraffin treatment. Overall, the collected information pointed towards the conclusion that paraffin baths may have some benefits for the treatment of patient’s hands that have RA. It was noted in this review that data is limited and there can be no definite conclusions about the benefits of paraffin baths. 

In the research review Thermotherapy for treating Rheumatoid Arthritis by Welch V. et al., researchers looked at different types of thermotherapy and their effectiveness for treating rheumatoid arthritis. Interventions other than paraffin were hot pack, cold pack, faradic bath, and therapeutic ultrasound. Using objective measures such as pain rating, swelling, grip strength, ROM, medication intake, and hand function, they found statistically significant results favoring paraffin wax combined with exercise. Hot pack, cold pack, cryotherapy, and faradic baths were found to have no significant affect on the objective measures. Researchers found no negative effects for any of the types of thermotherapy. It was concluded in this review that thermotherapy, especially wax baths, may be used as palliative therapy and adjunct therapy along with therapeutic exercises.

In the research review Validation of the Comprehensive International Classification of

Functioning, Disability and Health Core Set for Rheumatoid Arthritis:

The Perspective of Physical Therapists by Inge Kirchberger et al., researchers looked at the ICF Core Set used by physical therapists for Rheumatoid Arthritis. PTs were surveyed about their intervention goals using a 3-round Delphi system. Eighty-two physical therapists from twelve countries participated in the study. Examiners concluded that the most relevant interventions for RA were thermotherapy, dynamic exercise and balance therapy, patient education, and electrical stimulation.

Research refuting use of paraffin bath/thermotherapy:

A study by Harris and Millard (1955) examined the effect of paraffin baths on RA. This study examined ninety patients with RA and divided them into three groups. Group one received no local treatment to the hands, group two received paraffin baths every day for three weeks for the hands, and the last group received paraffin baths every day for six weeks for the hands. No other local treatment was applied to the hands during the study, but each subject was undergoing a general physical rehabilitation program for RA. The subjects were examined two days prior to the beginning of treatment to allow for a base measurement then were examined each week for the duration of six weeks. Tenderness, swelling, and pain were measured on a scale of 0 to three in order of increasing severity. Grip, dexterity, and erythrocyte sedimentation rate (ESR) was also measured. The total overall impression was measured after the six week on a scale of -1 to 3 with -1 being worsened condition and 3 being major gains. It was found that the changes from week to week were so small that no useable information could be obtained. Each group had made similar subjective and objective progress after the first three weeks of the study. At the end of the sixth week it was found that groups one and three had similar slight progress for grip, swelling, and dexterity while the second group had worsened. Overall, the results show that the subjects did not receive any benefit from the paraffin baths.

Several studies conclude that paraffin bath therapy is not effective when used alone (i.e. when not paired with therapeutic exercise). One such study, whose purpose it was to create guidelines for thermotherapy interventions for adult patients with RA, was done by Ottawa Panel Members et al. This study lists nine goals for the management of RA: decrease pain, decrease joint swelling, decrease stiffness, correct or prevent joint deformity, increase ROM, increase muscle force/decrease weakness, improve mobility, reduce fatigue, and increase functional status. In the portion of this article pertaining to paraffin wax, they found no statistically significant difference for patients who had wax applied to the hand and wrist versus a control after one month. It was, however, shown that wax combined with exercise versus a control has clinically important benefits. So, the article concludes that paraffin wax, as a treatment alone, is ineffective.

The review Non-drug treatment (excluding surgery) in rheumatoid arthritis: Clinical practice guidelines by Romain Forestier et al. aimed to establish guidelines for physical therapy use in union with drug treatment in patients with RA. Researchers compiled reviews spanning from 1985-2006 from online databases (MEDLINE, EMBASE, CINAHL, Pascal, Cochrane, National Guideline Clearinghouse, HTA database, and PEDRO). “Each study was allocated an evidence level. The grade of a guideline depended on the evidence level of the studies. When no grade could be allocated, working group members attempted to reach ‘professional agreement’ on specific topics.” (Forestier, R…) The researchers found that heat treatment, as well as ultrasound, had a low level of evidence and concluded that the benefits were short-lasting and should not be used as primary treatment.

Conclusion:

According to current literature, paraffin bath is a supported form of thermotherapy for treatment of RA. The amount of research available on this topic was limited, indicating that more research on the topic would be beneficial.

Summaries provided by Chelsea K., Kelci M., and Shannon L.

References:

Prentice, W. E. (2011). Therapeutic modalities in rehabilitation, fourth edition. McGraw-Hill Companies.

Kirchberger I., Glaessel A., Stuckl G., Cleza A. (2007). Validation of the comprehensive international classification of functioning, disability and health core set for rheumatoid arthritis: The perspective of physical therapists . (Vol. 87, pp. 368-384). American Physical Therapy Association. Retrieved from http://www.physther.net/content/87/4/368.full

Marks, R., & Ayling, J. (1995). Efficacy of Paraffin Wax Baths for Rheumatoid Arthritis. Physiotherapy, 190-201.

Welch V, Brosseau L, Casimiro L, Judd M, Shea B, Tugwell P, Wells GA. Thermotherapy for treating rheumatoid arthritis. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD002826. DOI: 10.1002/14651858.CD002826.

Harris, R., & Millard, J. B. (1955). Paraffin-wax baths in the treatment of rheumatoid arthritis. Annals of the rheumatic diseases, 14(3), 278-82. 

Members, O. P., O. M. Members, et al. (2004). "Ottawa Panel Evidence-Based Clinical Practice Guidelines for Electrotherapy and Thermotherapy Interventions in the Management of Rheumatoid Arthritis in Adults." Physical Therapy 84(11): 1016-1043.

Forestier, R., André-Vert, J., Guillez, P., Coudeyre, E., Lefevre-Colau, M.-M., Combe, B., & Mayoux-Benhamou, M.-A. (2009). Non-drug treatment (excluding surgery) in rheumatoid arthritis: Clinical practice guidelines. Joint Bone Spine, 76(6), 691-698. doi: 10.1016/j.jbspin.2009.01.017

Commercial Cold Packs - Are They Necessary?

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

Moist Hot Pack and Low Back Pain

Ann B., Laura S., Brandon W.

Managing low back pain can be very challenging as there are many nonsurgical therapies to choose from as treatment options. Heat is often used as a universal treatment for pain and discomfort. One traditional therapy that has been used to manage low back pain has been the use of moist heat packs. The physiologic responses of moist heat pack include increasing circulation, increasing muscle temperature, increasing tissue temperature, and relaxing spasms.

Supporting Evidence:

Nadler et al. looked at the difference between the use of continuous low-level heat versus the use of ibuprofen and acetaminophen in the treatment of acute low back pain. It was found that the heat wrap, when compared to the ibuprofen and acetaminophen respectively provided significantly better pain relief both on day one as well as days three and four. It also was found to provide decreased morning muscle stiffness, increased lateral trunk flexibility and decrease low back disability on day 4. In The Physiologic Basis and Clinical Applications of Cryotherapy and Thermotherapy for the Pain Practitioner, Steiner et al. found in a randomized controlled trial that continuous low-level heat therapy worn for eight hours a day over a three day period showed a significant increase in pain relief when compared to an unheated control treatment group. French et al. found that in a trial involving acute and sub-acute low-back pain patients, heat wrap therapy significantly reduced their low back pain after five days when compared to an oral placebo. They also looked at the effect of adding in exercise to the heat wrap therapy and found that it reduced pain after seven days.

Refuting Evidence:

Two main categories of modalities in treating chronic low back pain include electrotherapeutic modalities and physical agents. Poitras and Brosseau used a systemic review to evaluate the efficacy of these two main categories of modalities. As discussed in Evidence-informed management of chronic low back pain with transcutaneous electrical nerve stimulation, interferential current, electrical muscle stimulation, ultrasound, and thermotherapy, there are few studies which are found to support the use of thermotherapy. The only remarkable evidence shown was that TENS (transcutaneous electrical nerve stimulation) had an immediate effect on short-term pain relief, but had no impact on perceived disability or long-term pain. Petrofsky et al. examined the effectiveness of three heating modalities used on people that are overweight. The types of heat investigated included dry heat with a commercial chemical hot pack, hydrocollator heat packs, and whirlpool. Dry heat that maintains contact with the skin for a long time was found to be more effective than rapid moist heat, where the transfer of heat from the skin to the deep muscles was significantly impaired by thicker layers of subcutaneous fat.  Garra et al. compared heat and cold packs for neck and back strain with the use of ibuprofen therapy. A randomized controlled trial of efficacy found that using heat and cold packs had mild, but similar improvement in pain severity. In addition, there were no differences in pain scores between the heat and cold groups both before and after treatment.

In conclusion, the evidence supports the use of moist hot packs to manage low back pain.  Some of the literature, however, showed that other modalities (e.g. Cryotherapy, TENS, etc.) may also work to reduce pain, so more research is need to determine the most effective modality treatment.

References:

French, S. D., Cameron, M., Walker, B. F., Reggars, J. W., & Esterman, A. J. (2006). Superficial heat or cold for low back pain. Cochrane database of systematic reviews (Online), (1), CD004750. doi:10.1002/14651858.CD004750.pub2

Garra, G., Singer, A. J., Leno, R., Taira, B. R., Gupta, N., Mathaikutty, B., & Thode, H. J. (2010). Heat or cold packs for neck and back strain: a randomized controlled trial of efficacy. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 17(5), 484-9. doi:10.1111/j.1553-2712.2010.00735.x

Nadler, S. F., Steiner, D. J., Erasala, G. N., Hengehold, D. A., Hinkle, R. T., Beth Goodale, M., Abeln, S. B., et al. (2002). Continuous low-level heat wrap therapy provides more efficacy than Ibuprofen and acetaminophen for acute low back pain. Spine, 27(10), 1012-7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12004166

Nadler, S. F., Weingand, K., & Kruse, R. J. (2004). The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. Pain physician, 7(3), 395-9. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16858479

Petrofsky, J., Bains, G., Prowse, M., Gunda, S., Berk, L., Raju, C., Ethiraju, G., et al. (2009). Dry heat, moist heat and body fat: are heating modalities really effective in people who are overweight? Journal of medical engineering & technology, 33(5), 361-9. doi:10.1080/03091900802355508

Poitras, S., & Brosseau, L. (n.d.). Evidence-informed management of chronic low back pain with transcutaneous electrical nerve stimulation, interferential current, electrical muscle stimulation, ultrasound, and thermotherapy. The spine journal : official journal of the North American Spine Society, 8(1), 226-33. doi:10.1016/j.spinee.2007.10.022

Contrast Bath & Ankle Sprain

Contrast Bath
Garret B., Christine C., Sara K.

Our patient presents with a subacute ankle sprain. Swelling has recently subsided, but the patient is still having significant pain. Contrast bath was used for pain relief and transition from cryotherapy to thermotherapy. Since this was the patients first time, we decided to do a 3 to 1 ratio of hot to cold for 20 minutes. We ended with cold to help regulate the patient’s pain. Upon the next visit, we will observe for signs of swelling, at which point we will change the hot to cold ratio if needed.

From the little research regarding contrast bath, we found evidence both supporting and refuting this modality.

Supporting Evidence: Petrofsky et al found that superficial blood flow to the foot increased significantly with contrast bath. The plantar surface of the foot had more significant findings than the dorsal surface. Fiscus et al, found similar results stating that while it was unlikely that intramuscular temperature changed, there were still peripheral changes in blood flow. During the cold phase, vasoconstriction simply returned to baseline and didn’t drop below the resting temperature. This is relevant because the significant increase in blood flow brings added nutrients and oxygen to the healing tissues. Denegar et al found that contrast bath decreased patient’s pain level on a visual analog scale. They also showed that patient preference for hot , cold, or contrast therapy will effect patients perception of pain relief. Nearly half of the subjects preferred cold or contrast bath.

Refuting Evidence: Higgins et al, found that the warm whirlpool caused significantly greater increase in temperature than contrast bath. Contrast bath showed no fluctuation in temperature after 11 minutes whereas the warm whirlpool had a gradual increase for the whole 30 minute treatment. Myrer et al, had similar findings where the intramuscular temperature for contrast bath had slight increases in temperature, whereas the control group (hot whirlpool) had significant temperature increases. Therefore, contrast bath provides little to no physiological effect in the intramuscular tissues. According to Cote et al, contrast bath is believed to be able to reduce edema through a pumping action caused by vasodilation and vasoconstriction, however, there is no evidence to support this theory. Contrast bath was found to be contraindicated when trying to control edema and it actually caused an increase in edema for post-acute ankle sprains. Heat alone and contrast bath both caused an increase in edema during this study.

Overall, we found that the research regarding contrast bath was insufficient. We believe that more research needs to be done for this modality in the future in order to validate and regulate its use in the clinic. While it was found that thermotherapy produces similar results, contrast bath seems to be a good way to transition from cryotherapy to thermotherapy once the acute phase has passed. Contrast bath could also be a preferred modality for patients. We chose this for our patient due to his lack of edema and persistent pain.

References

Cote, Debra, William Prentice, Daniel Hooker, and Edgar Shields. "Comparison of Three Treatment Procedures for Minimizing Ankle Swelling." Physical Therapy. 68.7 (1988): 1072-1076. Web. 19 Jan. 2012. .

Denegar, Craig, et al. "Preferences for Heat, Cold, or Contrast in Patients with Knee Osteoarthritis Affect Treatment Response." Clinical Interventions in Aging 5 (2010): 199-206. PubMed. Web. 19 Jan. 2012. .

Fiscus, Kimberly, Thomas Kaminski, and Powers Michael. "Changes in Lower-Leg Blood Flow During Warm-, Cold-, and Contrast-Water Therapy." Archives of Physical Medicine and Rehabilitation. 86.7 (2005): 1404-1410. Web. 19 Jan. 2012. .

Higgins , Diana, and Thomas W Kaminski. "Contrast therapy does not cause fluctuations in human gastrocnemius intramuscular temperature." Journal of Athletic Training. 33.4 (1998): 336-41. Web. 19 Jan. 2012.

Myrer, J. W., Draper, D. O., & Durrant, E. (1994). Contrast therapy and intramuscular temperature in the human leg. Journal of athletic training, 29(4), 318-22.

Petrofsky, J, E III Lohman, S Lee, Z de la Cuesta, L Labial , R Iouciulescu, B Moseley, and R Korson. "Effects of contrast baths on skin blood flow on the dorsal and plantar foot in people with type 2 diabetes and age-matched controls.." Physiotherapy Theory & Practice. 23.4 (2007): 189-97. Web. 19 Jan. 2012.

Ice Massage & Plantar Fasciitis

Plantar fasciitis is a soft tissue injury characterized by inflammation of the plantar fascia.  This syndrome can occur both acutely and chronically from overstretching of the plantar fascia or by overuse.  There are a variety of methods to treat plantar fasciitis by controlling the inflammation.  Ice massage is one traditional modality used to treat this condition, however, the current research both supports and refutes its use.
Research Supporting the Use of Ice Massage

·      When applying ice massage to an injury, many benefits may be expected. Ice massage is often considered a primary treatment for plantar fasciitis because of its analgesic effects. According to study conducted by Anaya-Terroba et al., Effects of ice massage on pressure pain thresholds and electromyography activity postexercise,  when tested on a specific muscle group, the effects of ice massage have shown to increase a person’s pressure pain threshold, which is the amount of pressure required for sensation of pressure to change to pain. Additionally, surface EMG activity has shown greater activity after ice massage treatment. Both effects of ice massage can be considered highly desirable to a person hindered by plantar fasciitis by allowing greater muscle recruitment and activity tolerance.

·      In the study, Intramuscular temperature responses in the human leg to two forms of cryotherapy: Ice massage and ice bag by Zemke et al., the researchers compared muscle temperature responses to two types of cryotherapy: ice massage and ice bag.  The results of the study found that ice massage took about 18 minutes to achieve the lowest intramuscular temperature, and the ice bag took considerably longer at 28 minutes.  Although the study tested the temperature of the calf musculature, these findings can be applied to plantar fasciitis as well.  In an acute muscular injury, such as plantar fasciitis, ice massage can help cool the injured tissue very rapidly.  The beneficial effects of rapid cooling include decreasing the injured cells’ need for oxygen and reducing circulation to the site of injury which can help to lessen the effects of the inflammatory response.

·      In an investigation by Middleton and Kolodin, Plantar fasciitis-heel pain in athletes, the researchers talk about six specific areas that need to be addressed for the treatment of plantar fasciitis. One of the six areas consists of therapeutic modalities. The researchers highlight ice massage or bagged ice as a good treatment for acute plantar fasciitis because it controls swelling and will help relieve the discomfort the patient feels from the inflammatory process.

Research refuting the use of ice massage to treat plantar fasciitis:

·      In Plantar fasciitis: Diagnosis and therapeutic considerations, the author, Roxas, talks about a variety of treatment options for plantar fasciitis. Treating plantar fasciitis typically involves conservative treatment of the condition by using methods such as medication (NSAIDS), stretching, reduced weight bearing, orthotic considerations, strengthening, and ice massage. Ice massage has been concluded to only temporarily relieve foot pain in a research based study, but combined with these methods, plantar fasciitis typically resolves in 90% of cases.

·      The study, Treatment of plantar fasciitis in recreational athletes: two different therapeutic protocols by Karagounis et al., prescribes the accompanying use of acupuncture along with conservative treatments, rather than ice massage alone. The usage of acupuncture has been prescribed more often in the treatment of acute and chronic pain, so why not plantar fasciitis? The results of combining acupuncture with typical treatment resulted in a statistical decrease in pain perception by the patient when compared to traditional treatments alone. This indicates that acupuncture should be applied or considered when treating plantar fasciitis along with traditional treatments to decrease healing time.

·      The article The Use of Ice in the Treatment of Acute Soft-Tissue Injury by Bleakley et al., is a systematic review of randomized controlled trials assessing the evidence for cryotherapy as a treatment modality for soft tissue injuries.  Although ice has been found to decrease pain in a number of soft tissue injuries, it is less effective in controlling swelling based research of knee surgery rehabilitation.  It has been found that a single application of ice and compression had the same outcomes as no treatment in reducing pain and swelling in subjects with an ankle sprain.  At this time, a few studies have found minimal support for the use of ice in treatment of soft tissue injuries, however, a standardized mode and duration of treatment has not been determined.  Due to the lack of evidence for cryotherapy, ice massage should be used with caution in the treatment of soft tissue injuries including plantar fasciitis.

In conclusion, the literature supports the use of ice massage as a modality in the treatment of plantar fasciitis to reduce the inflammatory response and aid in pain relief.  However, more research is needed to determine the most effective use other conservative modalities used in combination with ice massage.  Additional research is needed to validate studies of alternative medicine used in combination with traditional treatments.  Future studies should also determine an optimal mode and duration for the use of ice massage.

References
Anaya-Terroba, L., Arroyo-Morales, M., Fernández-de-Las-Peñas, C., Díaz-Rodríguez, L., & Cleland, J. a. (n.d.). Effects of ice massage on pressure pain thresholds and electromyography activity postexercise: a randomized controlled crossover study. Journal of manipulative and physiological therapeutics, 33(3), 212-9.

Zemke, J. E., Andersen, J. C., Guion, W. K., McMillan, J., & Joyner, A. B. (1998). Intramuscular temperature responses in the human leg to two forms of cryotherapy: ice massage and ice bag. The Journal of orthopaedic and sports physical therapy, 27(4), 301-7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9549714

Middleton, J.A., and E.L. Kolodin. "Plantar fasciitis-heel pain in athletes." Journal of athletic training. 27.1 (1992): 70-5. Web. 19 Jan. 2012.

Karagounis, P., Tsironi, M., Prionas, G., Tsiganos, G., & Baltopoulos, P. (2011). Treatment of plantar fasciitis in recreational athletes: two different therapeutic protocols. Foot & ankle specialist, 4(4), 226-34. doi:10.1177/1938640011407320

Bleakley, C., McDonough, S., & MacAuley, D. (Jan 2004). The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. The American journal of sports medicine, 32(1), 251-61. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14754753

Roxas, Mario. "Alternative Medicine Review." Plantar Fasciitis: Diagnosis and Therapeutic Considerations. 10.2 (2005): 83-93. Web. 20 Jan. 2012.

Draper Ultrasound+Pack Articles

I believe the concept of preheating muscle tissue before application of US treatment showed the best evidence of increasing the baseline temperature of the muscle. With the presented articles I do believe that cooling a muscle before US provides poor evidence of heating a tissue (which, as stated, is the main goal).

With this, the question of whether or not application of a hot pack before US treatment is truly beneficial arises. Is applying a hot pack for 5-8 minutes worth charging a patient's insurance? To add, you would also be losing treatment time with your patient. Looking at the room temperature vs hot pack article, I would determine that the differences seen at between these treatments is not worth the time of applying a hot pack to a patient, as long as the sole purpose is to heat deeper tissue.

It should be mentioned, that with different patients, they may, or may not "feel the heat" of the US giving them a tendency to favor the hot pack alone because of the sensational feedback of the heat. Depending on the patient's preference or the physical therapists judgement, it could be debated whether hot/cold packs should be used at all, along with ultrasound.