From: "Michael Carstensen, D.C." Subject: ice vs heat.... Date: Thu, 20 Jan 2000 21:58:25 -0330 Docs, I would like to know if anyone has any convincing evidence that ice is indicated in acute injuries. I would also like to know if anyone can produce any convincing evidence that heat is contra-indicated. In addition, what is the primary goal of cryotherapy? Hyperemia? Analgesia? Thanks. Mike -------------- From: "7RCSX" <7RCSX@email.msn.com> Subject: Re: ice vs heat.... Date: Thu, 20 Jan 2000 20:50:52 -0600 >In addition, what is the primary goal of cryotherapy? Hyperemia? Analgesia?< Neither, posttrauma. It's to reduce swelling. Excessive swelling encourages circulatory engorgement, stasis. With stasis, you have a buildup of metabolic debris serving as an added chemical irritant. Best effects occur within first 12 hours. I prefer cool cloths to ice massage for weekend athletes. Strong warmth should be avoided first 72 hours. Heat increases local circulation (flushes) thus improves tissue nutrition and disperses stasis. Both modalities are helpful but must be closely monitored Nature appreciates a gentle nudge but resents a slap in the face. Sometimes its logical to apply mild heat indirectly before 72 hours; eg, to the plantar surface following a knee injury. I've often used coolness locally and warmth remotely simultaneously. Who said health care had to be an either/or choice? The most important thing to remember in postinjury situations is that the tissues are already overstressed. They don't need your adding to this. Apply your knowledge only when the normal physiologic response appears to have become excessive or retarded for the situation at hand. Understand completely the four stages of healing, and you will do fine. RCSchafer --------------- Date: Thu, 20 Jan 2000 20:35:16 -0500 From: "Stephen M. Perle, D.C." Subject: Re: ice vs heat.... I can't find the reference (read it in the days before I was EndNote organized) but there was a paper ~1988 in JSOPT where ankle volume was measured in two groups of patients with ankle sprains. One group was given heat and the other ice and the ice group had a statistically significant decrease in volume, I think. Stephen M. Perle, D.C. -------------- At 10:28 PM -0330 01/20/2000, Michael Carstensen, D.C. wrote: But is volume clinically significant? --------------- Date: Thu, 20 Jan 2000 21:17:32 -0500 From: "Stephen M. Perle, D.C." Subject: Re: ice vs heat.... Tell you how much swelling there is. Increased swelling is negatively correlated with rate of recovery. ------------- Date: Thu, 20 Jan 2000 18:15:32 -0800 From: "David N. Young DC" Subject: Re: ice vs heat.... written like someone who has never sprained an ankle (or any joint). "Stephen M. Perle, D.C. wrote: > I can't find the reference (read it in the days before I was EndNote > organized) but there was a paper ~1988 in JSOPT where ankle volume was > measured in two groups of patients with ankle sprains. One group was > given heat and the other ice and the ice group had a statistically > significant decrease in volume, I think. At 10:28 PM -0330 01/20/2000, Michael Carstensen, D.C. wrote: >But is volume clinically significant? David N. Young DC FACO ------------ From: drbodnar@ns.sympatico.ca (Mark Bodnar) Subject: Re: ice vs heat.... Date: Thu, 20 Jan 2000 23:43:55 -0400 Stephen M. Perle, D.C > I can't find the reference (read it in the days before I was EndNote > organized) but there was a paper ~1988 in JSOPT where ankle volume was > measured in two groups of patients with ankle sprains. One group was > given heat and the other ice and the ice group had a statistically > significant decrease in volume, I think. I found a reference (see below). Another study (I can't remember or find) if my memory serves - compared recovery rates from a mild ankle sprain - I think heat on an acute ankle sprain resulted in ~12-14 days for "healing", no ice or heat ~10 days and ice "healed" in ~7 days. Dr. Michael Carstensen > In addition, what is the primary goal of cryotherapy? Hyperemia? > Analgesia? I'd say the primary goal of cryotherapy is decreased swelling - I would'nt suggest that I have "convincing evidence" but I'll throw out a theory that sounds plausible --- swelling happens for a reason - specifically 1. to immobilize an injured joint and therefore reduce the likelihood of further injury, 2. to flood the area with WBC's to defend against any possible infection. While these are laudable goals the body tends to over react - I would argue that we can accelerate recovery by skipping this swelling step (which may actually interfere with effective scar tissue formation) by using ice. Skipping this step lets the body move directly to scar tissue formation and repair. Of course, if we choose to defeat the body's natural defence system we must ensure we're not causing more problems - therefore 1. protect against re-injury, 2. ensure there is no infectious infiltration. Dr. Mark Bodnar Title: Comparison of three treatment procedures for minimizing ankle sprain swelling. Author :Cot´e DJ; Prentice WE Jr; Hooker DN; Shields EW Address :Department of Physical Education, University of North Carolina, Chapel Hill 27599-8600. Source :Phys Ther, 68(7):1072-6 1988 Jul Abstract : The purpose of this study was to compare the effects of cold, heat, and contrast bath treatments on the amount of edema in first- and second-degree sprained ankles during the postacute phase of rehabilitation. Thirty subjects with postacute sprained ankles were assigned to a cold (n = 10), heat (n = 10), or contrast bath (n = 10) treatment group. A specially constructed tank was used to take pretreatment and posttreatment volumetric measurements of subjects' sprained ankles. Descriptive statistics, a 3 x 3 two-way analysis of variance for repeated measures, and Tukey's Honestly Significant Difference post hoc test revealed that cold therapy produced the least edema in subjects with sprained ankles (p less than .05). All three treatments (cold, heat, and contrast bath) produced an increase in the amount of edema in the postacute sprained ankles of the subjects. Heat and contrast bath therapy produced almost identical increases in the amount of ankle edema on each of the three days of the study. We concluded that cold therapy is the most appropriate of the three treatments if the therapeutic objective is to minimize edema before rehabilitative exercise during the third, fourth, and fifth days postinjury for first- and second-degree ankle sprains. Title: Cryotherapy in sports medicine. Author Swenson C; Sw¨ard L; Karlsson J Address Department of Orthopaedics, Ostra University Hospital, G¨oteborg, Sweden. Source Scand J Med Sci Sports, 6(4):193-200 1996 Aug Abstract The use of cryotherapy, i.e. the application of cold for the treatment of injury or disease, is widespread in sports medicine today. It is an established method when treating acute soft tissue injuries, but there is a discrepancy between the scientific basis for cryotherapy and clinical studies. Various methods such as ice packs, ice towels, ice massage, gel packs, refrigerant gases and inflatable splints can be used. Cold is also used to reduce the recovery time as part of the rehabilitation programme both after acute injuries and in the treatment of chronic injuries. Cryotherapy has also been shown to reduce pain effectively in the post-operative period after reconstructive surgery of the joints. Both superficial and deep temperature changes depend on the method of application, initial temperature and application time. The physiological and biological effects are due to the reduction in temperature in the various tissues, together with the neuromuscular action and relaxation of the muscles produced by the application of cold. Cold increases the pain threshold, the viscosity and the plastic deformation of the tissues but decreases the motor performance. The application of cold has also been found to decrease the inflammatory reaction in an experimental situation. Cold appears to be effective and harmless and few complications or side-effects after the use of cold therapy are reported. Prolonged application at very low temperatures should, however, be avoided as this may cause serious side-effects, such as frost-bite and nerve injuries. Practical applications, indications and contraindications are discussed. Language Eng Unique Identifier 97051352 ------------- From: "Dr. Sue White" Subject: Re: ice vs heat.... Date: Thu, 20 Jan 2000 21:29:06 -0500 I do not have the resources here at home, but I teach a hydrotherapy course - entry level - for students at a massage school. The founders of the school, both long-time chiropractors and bodywork professionals, put together an excellent course using referenced materials. So, that said, I will give the short-version basic synopsis of the work in anticipation of getting the references for you: Rationale for ice in acute injuries: mostly analgesic, but some mediation of the effect of histamines and other NT's which are drawn to the injured area via chemotaxis (i.e., substance P, serotonin, and bradykinin mainly). After the initial body response of vasodilation, so that fibrinogen, macrophages, and other helper chemicals can help repair the leak, ice helps the body to seal off the injured area so the goodies can go to work and help the area not get too flooded with extracellular fluid. Rationale for no heat pre- 48 -72 hours (dependent on tissue healing ability of the individual): Now that the fibrinogen is being converted into fibrin to form the "clot" (or fibrous scar tissue) and the healing process has begun, you do not want heat to dissolve the fragile bonds that are being created. IN addition, the heat will vasodilate the area, bringing with it more extracellular fluid, which can stress the area's already damaged and dysfunctional draining system -- the body is still healing, so it can not get the extra fluid out the way that functional, normal tissue can. Residual inflammation, metabolic waste products, and fibrotic inclusions can physically compress the venous and lymphatic drainage systems, so the area stays mired in acidic waste and other by-products of the healing process (chemical and cellular residues, etc. IN other words, heat can "melt" the healing scar, making the body start the process all over again, with more fibrotic tissue the result. Hope this helps -- will get you references next time I am at the school... SDW, DC -------------- From: "Richard Gillespie, DC" Subject: Re: ice vs heat.... Date: Fri, 21 Jan 2000 08:19:00 -0600 Could I ask this list to expand this discussion a little further? I have always used hot packs and/or sinewave muscle stimulation as an adjunct to my adjustment. My rationale is that it relaxes the patient and the adjustment seems more effective. I charge an extra $10 for these modalities. Now, more and more, insurance companies are cutting these charges after 3 to 4 weeks stating that they are ineffective after the acute phase of injury. I contend that the patient responds better and faster and will continue to use it even if I am not compensated for it. Is there any clinical or scientific evidence that I can quote to back up my claims that these modalities are effective beyond the acute stage? Thanks -------------- From: "7RCSX" <7RCSX@email.msn.com> Subject: Re: efficacy of hot packs/sine wave (was Re: ice vs heat....) Date: Fri, 21 Jan 2000 13:09:44 -0600 Let us reason together for a moment. How is the body's lymphatic and venous supply transported from the periphery to the liver and lungs for purification? Obviously, it is essentially achieved by muscle contraction and a system of one-way valves. Muscle contraction provides a squeezing, milking-like, pump action. This, in turn, encourages optimal tissue nutrition and the flushing of metabolic debris. I see nowhere in the 2--5 stages of healing where this effect would not usually be beneficial. I see nowhere in the 2--5 stages of healing where this effect would be contraindicated under typical circumstances. Also, to provide a service to a patient because it is deemed right to do so, whether financially compensated or not, reflects what health care is all about. Dr. Gillespie, I salute you. RCSchafer ---------------- Date: Fri, 21 Jan 2000 20:43:56 -0800 From: "Carmine J. Gangemi" Subject: ice vs heat, continued... Doctors, I was always under the impression that the application of ice to an acute injury was "unquestionable". I was always taught: "RICE", that being rest, ice, compression, and elevation. As of late I have heard of applications of heat, applied very early, to an acute injury being of benefit. I have not seen an article supporting this though. Maybe Dr. Matt Worth could post the article he mentioned earlier. I think that it's also appropriate to include the cardinal signs of inflammation as part of our discussion. Rubor, tumor, calor, dolor, and function laesa, (redness, swelling, heat, pain, and loss of function). And, as Dr. Bodnar stated: "...the body tends to over react...". I think that most of us on this list would agree with that statement in regards to acute trauma and inflammation. Ice therefore would reduce the body's "over reaction". To support this, Robbins' "Pathological Basis of Disease", 5th Edition, states on page 64: "At this point it would be profitable to review the events in acute inflammation discussed so far. The vascular phenomena are characterized by increased blood flow to the injured area, resulting mainly from arteriolar dilatation and opening of capillary beds. Increased vascular permeability results in the accumulation of protein-rich extravascular fluid, which forms the exudate. Plasma proteins leave the vessels, most commonly through widened interendothelial cell junctions of the venules or by direct endothelial cell injury. The leukocytes, initially predominantly neutrophils, adhere to the endothelium via adhesion molecules, transmigrate across the endothelium, and migrate to the site of injury under the influence of chemotactic agents. Phagocytosis of the offending agent follows, which may lead to the death of the microorganism. During chemotaxis and phagocytosis, activated leukocytes may release toxic metabolites and proteases extracellularly, potentially causing tissue damage"(Robbins, p 64). An immediate application of ice would thus reduce the arteriolar dilatation and lessen the cascade of events which follows. This intern decreases the release of toxic metabolites and proteases extracellularly by the leukocytes. I would also question the osmotic effect that protein-rich extravascular fluid has on the related tissues. Wouldn't an osmotic shift have the potential to cause further damage? I think that the true question to ice application is incomplete until the severity of the injury is considered. If there is trauma that results in the immediate death of a large amount of tissue then I wonder if slowing the cascade of the body's response would also slow the removal of the dead cells and thus the healing process. (Comments?) Also, when should heat be introduced? Should ice and heat be used alternatively? When should ice applications be discontinued? Further, I would like to thank Dr. Schafer for his always enlightening insites on such topics. And I'd like to apologize to those on the list who would view my questions as redundant. Sincerely, Dr. Carmine J. Gangemi, Chiropractic Extern ---------------- From: "Frank-meister" Subject: Re: ice vs heat.... Date: Fri, 21 Jan 2000 12:51:24 -0600 Mike, when you ask "But is volume clinically significant?"...it sure was to me when my ankle was sprained. I had it adjusted (anterior talus and "medial" calcaneus) , and the swelling dropped drastically in hours (not days, as was usual in the past). It was clinically relevant to me...of course, I understand you are interested in published commentary, not testimonials, but often published findings just hypothesize what we see in a clinical encounter, no? Frank M. Painter, D.C. -------------- From: "Michael Carstensen, D.C." Subject: Re: ice vs heat.... Date: Sat, 22 Jan 2000 17:35:08 -0330 > I found a reference (see below). Another study (I can't remember or find) > if my memory serves - compared recovery rates from a mild ankle sprain - I > think heat on an acute ankle sprain resulted in ~12-14 days for "healing", > no ice or heat ~10 days and ice "healed" in ~7 days. Maybe the definition of healed related to weight bearing or pain level? What if our introduction of ice or analgesics decreased the amount of inflammation so that the pain level decreased sooner? What if that decreased the time to lay down scar tissue and resulted in a loss of overall tissue strength? > I'd say the primary goal of cryotherapy is decreased swelling - I would'nt > suggest that I have "convincing evidence" but I'll throw out a theory that > sounds plausible --- swelling happens for a reason - specifically 1. to > immobilize an injured joint and therefore reduce the likelihood of further > injury, 2. to flood the area with WBC's to defend against any possible > infection. While these are laudable goals the body tends to over react - I > would argue that we can accelerate recovery by skipping this swelling step > (which may actually interfere with effective scar tissue formation) by using > ice. Skipping this step lets the body move directly to scar tissue > formation and repair. This initial phase of injury is to call the appropriate blood based constituents to the scene. WBCs, platelets, etc are all brought to the locale to cause a clot, which, to the best of my understanding, serves as a matrix for the invading fibroblasts to deposit collagen on. Mike Dr. Michael Carstensen St. John's, Newfoundland ------------------- From: o.lanlo@libertysurf.fr Subject: Re: ice vs heat.... Date: Fri, 21 Jan 2000 16:14:04 +0100 Dr Carstensen, First, conserning the fact that ice is indicated in acute injuries I would say yes. The way cryotherapy is working might be: -descrease nerves(nocicptive)conduction -descrease blood flow -prevent or reduce edema The studies in references show a real benefit in using cryotherapy after trauma or acute injuries. ref: 1-Cryotherapy as an analgesic technique in direct, postopérative treatement following elective joint replacement Albrecht S, and Al Z Orthop Ihre Grenzgeb 1997 Jan-Fev;135(1):45-51 2-Use cryotherapy for orthpeadic patients McDowell JH, McFarland EG, Nalli BJ Ortop Nurs 1994 Sep-Oct;13(5):21-30 3-Clinical benefits of early cold therapy in accident and emergency following ankle sprain. Sloan JP, Hain R, Pownall R Arch Emerg Med 1989 Mar;6(1):1-6 4-Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy. Ernst E, Fialka V J Pain Symptom Manage 1994 Jan;9(1):56-9 5-Cryotherapy in sport medicine Swenson C, Sward L, Karlsson J Scand J Med Sci Sports 1996 Aug;6(4):193-200 There is differents modalities for cold applications, you can do ice massage,ice bag in continue, or ice bag (cold pack) in prolonged intermittent applications (20 min on;10 min off; 10 min on; 10 min off; 10 min on ). Regarding the following studies physiologicals changes only appear up to 20 min application. 6-Changes in forearm blood flow during single and intermittent cold application. Karunakara RG, Lephart SM, Pincivero DM J Orthop Sports Phys Ther 1999 Mar;29(3):177-80 7-Changes in local blood volume during cold gel pack application to traumatized ankles. Weston M, Taber C J Orthop Sports Phys Ther 1994 Apr;19(4):197-9 8-Intramuscular temperature responses in human leg to tow forms of cryotherapy : ice massage and ice bag. Zemke JE, Andersen JC, Guion WK J Orthop Sports Phys Ther 1998;27(4):301-7 There is possible complications with using cold therapy, nerves injuries is the major one. But it's generaly resolved spontaneously. This fact could be avoid by not using cold pack more than 30 min in single application. 9-Cryotherapy and nerve palsy. Drez D, Faust DC, Evans JP Am J Sports Med 1981 Jul-Aug(4):256-7 10-Cryotherapy-induced nerve injury Basset FH 3rd, et al Am J Sports Med 1992 Sep-Oct;20(5):516-8 Concerning heat therapy and contradication in acute injuries, I think there is evidence that heat increase sweelling, blood flow and inflamation. It is contra-indicated in the early stage of muscle hematoma (risk of calcification). The benefit of heat application is better in chronic torpid and proliferous inflamations. 11-Heat, cold and inflamation. Schmidt Kl, Ott VR, Rocher G, Schaller H Z Rheumatol 1979 Nov-Dec;38(11-12):391-404 12-Themal modalities: heat and cold. A review of physiologic effects with clinical applications. Nanneman D AAOHN J 1991 Feb;39(2):70-5 I hope this can help you Sincerely, Olivier Lanlo D.C. Rennes, France --------------------------- Date: Mon, 31 Jan 2000 18:09:13 -0500 (EST) From: "Stephen Perle, DC" Subject: HOT AND COLD (fwd) More on the topic from Sportscience mailing list There has been much written on this topic over the past week and many of the posts are expressing empirical evidence either confirming or denying the use of heat or cold. I would encourage those interested to pick up a copy of Ken Knights Cryotherapy text as it is highly informative as to the past research on Cold therapy. A key point in his text states several basic premises that he builds on in this text. They are as follows: Basic suppositions about ice and its effects of the body: 1. Vasodilation does not occur during most, if any, therapeutic applications of cold. 2. The benefits of therapeutic cold application during both immediate care and rehabilitation are unrelated to the circulatory effects of cold. 3. The benefits of cold applications during immediate care procedures are due to metabolic effects rather than vasoconstriction. Concerning this topic, it is interesting to hear the number of posts promoting the importance of cold due to its vasoconstrive effects when in fact the reason for using cold as a first aid tool is via its metabolic effects and the subsequent ability for cold to decrease secondary cell death caused by localized hypoxia. The decreased metabolic effects can minimize this secondary hypoxia. 4. During rehabilitation procedures, cold applications are beneficial in decreasing pain and muscular spasm in preparation for exercise. 5. Without properly executed therapeutic exercise, cold applications will hinder rather than promote rehabilitation. This point is interesting in light of the topic of what type of environment promotes the best recovery after exercise. Knight's text points to animal studies that demonstrated slowed wound healing as well as decreased tensile strength of healing incisions when treated with hypothermic conditions (Knight, pg 152). Personally, I have always wondered if mass icing of pitchers arms after throwing or basketball players knees after a hard workout was more detrimental than helpful to those individuals who have no past history of post injury soreness/pain because of the decreased metabolic effects of the tissue. One other comment concerning the use of heat and cold to help with swelling. Some of the previous posts have stated or illuded to the use of vasodilation/constriction as a means of pumping out fluid from the area being treated. Doesn't heat increase transudation of fluids out of the cell and into the extracellular spaces via the dilatory effects of the vessels? And if there is excessive fluid in the extracellular spaces, isn't it the role of the lymphatic system primarily by muscle contractions and to a lesser degree via elevation to move this fluid up the lymphatic vessels and back into the heart? If so, then why would we even want to use contrasts or heat to perform this role? Just some thoughts to consider. Ken Heck Asst. Prof. Asst. ATC Messiah College Grantham Pa kheck@messiah.edu ----------------------