Does Cryotherapy Improve Outcomes With Soft Tissue Injury?

REFERENCE: Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sport Med. 2004; 32:251-261. CLINICAL QUESTION: What is the clinical evidence base for cryotherapy use? DATA SOURCES: Studies were identified by using a computer-based literature search on a total of 8 databases: MEDLINE, Proquest, ISI Web of Science, Cumulative Index to Nursing and Allied Health (CINAHL) on Ovid, Allied and Complementary Medicine Database (AMED) on Ovid, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effectiveness, and Cochrane Controlled Trials Register (Central). This was supplemented with citation tracking of relevant primary and review articles. Search terms included surgery,orthopaedics,sports injury,soft tissue injury,sprains and strains,contusions,athletic injury,acute,compression, cryotherapy,ice,RICE, andcold. STUDY SELECTION: To be included in the review, each study had to fulfill the following conditions: be a randomized, controlled trial of human subjects; be published in English as a full paper; include patients recovering from acute soft tissue or orthopaedic surgical interventions who received cryotherapy in inpatient, outpatient, or home-based treatment, in isolation or in combination with placebo or other therapies; provide comparisons with no treatment, placebo, a different mode or protocol of cryotherapy, or other physiotherapeutic interventions; and have outcome measures that included function (subjective or objective), pain, swelling, or range of motion. DATA EXTRACTION: The study population, interventions, outcomes, follow-up, and reported results of the assessed trials were extracted and tabulated. The primary outcome measures were pain, swelling, and range of motion. Only 2 groups reported adequate data for return to normal function. All eligible articles were rated for methodologic quality using the PEDro scale. The PEDro scale is a checklist that examines the believability (internal validity) and the interpretability of trial quality. The 11-item checklist yields a maximum score of 10 if all criteria are satisfied. The intraclass correlation coefficient and kappa values are similar to those reported for 3 other frequently used quality scales (Chalmers Scale, Jadad Scale, and Maastricht List). Two reviewers graded the articles, a method that has been reported to be more reliable than one evaluator. MAIN RESULTS: Specific search criteria identified 55 articles for review, of which 22 were eligible randomized, controlled clinical trials. The articles' scores on the PEDro scale were low, ranging from 1 to 5, with an average score of 3.4. Five studies provided adequate information on the subjects' baseline data, and only 3 studies concealed allocation during subject recruitment. No studies blinded their therapist's administration of therapy, and just 1 study blinded subjects. Only 1 study included an intention-to-treat analysis. The average number of subjects in the studies was 66.7; however, only 1 group undertook a power analysis. The types of injuries varied widely (eg, acute or surgical). No authors investigated subjects with muscle contusions or strains, and only 5 groups studied subjects with acute ligament sprains. The remaining 17 groups examined patients recovering from operative procedures (anterior cruciate ligament repair, knee arthroscopy, lateral retinacular release, total knee and hip arthroplasties, and carpal tunnel release). Additionally, the mode of cryotherapy varied widely, as did the duration and frequency of cryotherapy application. The time period when cryotherapy was applied after injury ranged from immediately after injury to 1 to 3 days postinjury. Adequate information on the actual surface temperature of the cooling device was not provided in the selected studies. Most authors recorded outcome variables over short periods (1 week), with the longest reporting follow-ups of pain, swelling, and range of motion recorded at 4 weeks postinjury. Data in that study were insufficient to calculate effect size. Nine studies did not provide data of the key outcome measures, so individual study effect estimates could not be calculated. A total of 12 treatment comparisons were made. Ice submersion with simultaneous exercises was significantly more effective than heat and contrast therapy plus simultaneous exercises at reducing swelling. Ice was reported to be no different from ice and low-frequency or high-frequency electric stimulation in effect on swelling, pain, and range of motion. Ice alone seemed to be more effective than applying no form of cryotherapy after minor knee surgery in terms of pain, but no differences were reported for range of motion and girth. Continuous cryotherapy was associated with a significantly greater decrease in pain and wrist circumference after surgery than intermittent cryotherapy. Evidence was marginal that a single simultaneous treatment with ice and compression is no more effective than no cryotherapy after an ankle sprain. The authors reported ice to be no more effective than rehabilitation only with regard to pain, swelling, and range of motion. Ice and compression seemed to be significantly more effective than ice alone in terms of decreasing pain. Additionally, ice, compression, and a placebo injection reduced pain more than a placebo injection alone. Lastly, in 8 studies, there seemed to be little difference in the effectiveness of ice and compression compared with compression alone. Only 2 of the 8 groups reported significant differences in favor of ice and compression. CONCLUSIONS: Based on the available evidence, cryotherapy seems to be effective in decreasing pain. In comparison with other rehabilitation techniques, the efficacy of cryotherapy has been questioned. The exact effect of cryotherapy on more frequently treated acute injuries (eg, muscle strains and contusions) has not been fully elucidated. Additionally, the low methodologic quality of the available evidence is of concern. Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury.

Does Cryotherapy Hasten Return to Participation? A Systematic Review.

OBJECTIVE: To search the English-language literature for original research addressing the effect of cryotherapy on return to participation after injury. DATA SOURCES: We searched MEDLINE, the Physiotherapy Evidence Database, SPORT Discus, the Cochrane Reviews database, and CINAHL from 1976 to 2003 to identify randomized clinical trials of cryotherapy. Key words used were cryotherapy, return to participation, cold treatment, ice, injury, sport, edema, and pain. DATA SYNTHESIS: Original research, including outcomes-assessment measures of return to participation of injured subjects, was reviewed using the Physiotherapy Evidence Database (PEDro) Scale. Four studies were identified and reviewed by a panel of certified athletic trainers. The 4 articles' scores ranged from 2 to 4 on the PEDro scale, which has a maximum of 10 points. Two of the articles suggested that cryotherapy speeds return to participation after ankle sprains. However, these authors failed to provide in-depth statistical analysis of their results. A confounding factor of compression as part of the treatment prevented interpretation of the effects of cryotherapy in 1 article. CONCLUSIONS: After critically reviewing the literature for the effect of cryotherapy on return-to-participation measures, we conclude that cryotherapy may have a positive effect. Despite the extensive use of cryotherapy in the management of acute injury, few authors have actually examined the effect of cryotherapy alone on return-to-participation measures. The relatively poor quality of the studies reviewed is of concern. Randomized, controlled clinical studies of the effect of cryotherapy on acute injury and return to participation are needed to better elucidate the treatment responses.

Prophylactic Ankle Taping and Bracing: A Numbers-Needed-to-Treat and Cost-Benefit Analysis.

OBJECTIVE: Taping and bracing are thought to decrease the incidence of ankle sprains; however, few investigators have addressed the effect of preventive measures on the rate of ankle sprains. Our purpose was to examine the effectiveness of ankle taping and bracing in reducing ankle sprains by applying a numbers-needed-to-treat (NNT) analysis to previously published studies. DATA SOURCES: We searched PubMed, CINAHL, SPORT Discus, and PEDro for original research from 1966 to 2002 with key words ankle taping, ankle sprains, injury incidence, prevention, ankle bracing, ankle prophylaxis, andnumbers needed to treat. We eliminated articles that did not address the effects of ankle taping or bracing on ankle injury rates using an experimental design. DATA SYNTHESIS: The search produced 8 articles, of which 3 permitted calculation of NNT, which addresses the clinical usefulness of an intervention by providing estimates of the number of treatments needed to prevent 1 injury occurrence. In a study of collegiate intramural basketball players, the prevention of 1 ankle sprain required the taping of 26 athletes with a history of ankle sprain and 143 without a prior history. In a military academy intramural basketball program, prevention of 1 sprain required bracing of 18 athletes with a history of ankle sprain and 39 athletes with no history. A study of ankle bracing in competitive soccer players produced an NNT of 5 athletes with a history of previous sprain and 57 without a prior injury. A cost- benefit analysis of ankle taping versus bracing revealed taping to be approximately 3 times more expensive than bracing. CONCLUSIONS/RECOMMENDATIONS: Greater benefit is achieved in applying prophylactic ankle taping or bracing to athletes with a history of ankle sprain, compared with those without previous sprains. The generalizability of these results to other physically active populations is unknown.

Differences in Postural Control During Single-Leg Stance Among Healthy Individuals With Different Foot Types.

OBJECTIVE: To identify differences in postural control among healthy individuals with different architectural foot types. DESIGN AND SETTING: We compared postural control during single-leg stance in healthy individuals with cavus, rectus, and planus foot types in our athletic training research laboratory. SUBJECTS: Thirty healthy, young adults (15 men, 15 women; age, 21.9 +/- 2.0 years; mass, 71.6 +/- 16.7 kg; height, 168.4 +/- 13.6 cm) had their feet categorized based on rearfoot and forefoot alignment measures. The right and left feet of a subject could be classified into different categories, and each foot was treated as a subject. There were 19 cavus, 23 rectus, and 18 planus feet. MEASUREMENTS: Subjects performed three 10-second trials of single-leg stance on each leg with eyes open while standing on a force platform. Dependent measures were center-of-pressure (COP) excursion area and velocity. RESULTS: Subjects with cavus feet used significantly larger COP excursion areas than did subjects with rectus feet. However, COP excursion velocities were not significantly different among foot types. CONCLUSIONS: Clinicians and researchers assessing postural control in single-leg stance with measures of COP excursion area must be cognizant of preexisting differences among foot types. If individuals' foot types are not taken into account, the results of clinical and research investigations assessing COP excursion area after injury may be confounded.

Can Chronic Ankle Instability Be Prevented? Rethinking Management of Lateral Ankle Sprains.

OBJECTIVE: To pose the question, "Can chronic ankle instability be prevented?" The evaluation and treatment of chronic ankle instability is a significant challenge in athletic health care. The condition affects large numbers of athletes and is associated with reinjury and impaired performance. The management of acute injuries varies widely but in athletic training has traditionally focused on initial symptom management and rapid return to activity. A review of practice strategies and philosophies suggests that a more detailed evaluation of all joints affected by the injury, correction of hypomobility, and protection of healing structures may lead to a more optimal long-term outcome. BACKGROUND: Sprains to the lateral ankle are common in athletes, and the reinjury rate is high. These injuries are often perceived as being isolated to the anterior talofibular and calcaneofibular ligaments. It is, however, becoming apparent that a lateral ankle sprain can injure other tissues and result in joint dysfunction throughout the ankle complex. DESCRIPTION: We begin by addressing the relationship between mechanical and functional instability. We then discuss normal ankle mechanics, sequelae to lateral ankle sprains, and abnormal ankle mechanics. Finally, tissue healing, joint dysfunction, and the management of acute lateral ankle sprain are reviewed, with an emphasis on restoring normal mechanics of the ankle-joint complex. A treatment model based on assessment of joint function, treatment of hypomobile segments, and protection of healing tissues at hypermobile segments is described.

Serial Testing of Postural Control After Acute Lateral Ankle Sprain.

OBJECTIVE: To identify subjects' changes in postural control during single-leg stance in the 4 weeks after acute lateral ankle sprain. DESIGN AND SETTING: We used a 2 x 2 x 3 (side-by-plane-by-session) within-subjects design with repeated measures on all 3 factors. All tests were performed in a university laboratory. SUBJECTS: Seventeen young adults (9 men, 8 women; age, 21.8 +/- 5.9 years; mass, 74.9 +/- 10.5 kg; height, 176.9 +/- 7.1 cm) who had sustained unilateral acute mild or moderate lateral ankle sprains. MEASUREMENTS: Measures of center-of-pressure excursion length, root mean square velocity of center-of-pressure excursions (VEL), and range of center-of-pressure excursions (RANGE) were calculated separately in the frontal and sagittal planes during 5-second trials of static single-leg stance. RESULTS: We noted significant side-by-plane-by-session interactions for magnitude of center-of-pressure excursions in a given trial (PSL) (P =.004), VEL (P =.011), and RANGE (P =.009). Both PSL and VEL in the frontal plane were greater in the injured limbs compared with the uninjured limbs on day 1 and during week 2 but not during week 4, whereas sagittal-plane differences existed during all 3 testing sessions. Injured-limb, frontal-plane RANGE scores were greater than uninjured values at day 1 but not during weeks 2 or 4. No significant differences in sagittal-plane RANGE scores were seen. CONCLUSIONS: Postural control was significantly impaired in the injured limbs at day 1 and during week 2 after lateral ankle sprain but not during week 4. Consistent improvement in postural control measures on both injured and uninjured limbs was seen throughout the 4 weeks after ankle sprain.

Educational History, Employment Characteristics, and Desired Competencies of Doctoral-Educated Athletic Trainers.

OBJECTIVE: The study had 3 objectives: (1) to assess the educational history of doctoral-educated certified athletic trainers (ATCs) who work at academic institutions, (2) to determine the current employment characteristics of doctoral-educated ATCs who work at academic institutions, and (3) to identify which competencies doctoral-educated ATCs feel are important for new doctoral graduates to possess upon graduation. DESIGN AND SETTING: Multiple sources were used to identify doctoral-educated ATCs who work at academic institutions. These individuals were surveyed to assess their educational histories, current employment characteristics, and opinions on desired competencies for new doctoral graduates. Data were analyzed using descriptive and inferential statistics. SUBJECTS: Surveys were sent to 130 individuals, and the response rate was 89.2% (n = 116). MEASUREMENTS: Subjects answered questions regarding their educational history and employment characteristics. A 5-point Likert scale was used to assess the importance of 22 competencies for new doctoral graduates to possess upon graduation. Comparisons were made between program directors and non-program directors, respondents employed at doctoral-granting institutions and non-doctoral-granting institutions, and doctoral student advisors and non-advisors. RESULTS: Subjects reported several different educational backgrounds, job titles, and job responsibilities. Significant differences in job responsibilities and assessment of desired competencies were found between program directors and non-program directors, employees of doctoral-granting institutions and non-doctoral-granting institutions, and doctoral student advisors and non-advisors. CONCLUSIONS: As new doctoral programs are established in athletic training, students should receive training as classroom instructors and program administrators, in addition to learning the skills necessary to perform independent research in athletic training.