Evidence Based Practice

Cold and Heat

Michael G. Dolan, MA, ATC Professor/Athletic Trainer Director, Sports Medicine Research Laboratory Canisius College Buffalo, NY

2008 EATA Meeting at Valley Forge Show Me the Evidence! What is Evidence-Based Practice?

Best Research

Clinical Experience Patient Values

2008 EATA Meeting at Valley Forge Cold, Heat, and Some Electricity

2008 EATA Meeting at Valley Forge Evidence-Based Practice

Where are we today? Where do we want to go?

Lots of theories Large Scale Randomized Clinical Testimonials Trials that examine Education & our treatments and manufacturer driven determine our clinical practice Uninjured human subjects Get Involved! Animal Models Some RCT’s Top Ten Things an Athletic Trainer Says

1. Put some ice on it Does it? If so, which treatments are most effective? How can we optimize our treatments? The most common clinical practice in sports medicine

† “Put some ice on it” † Does ice reduce swelling after an ankle sprain? † Does it hasten recovery? Systematic Review of on Return to Play

† 83 relevant clinical trials † 79 were excluded because they did not include return to play as an outcome † 4 reviewed studies 2 had a 1 had a positive effect 1 showed no positive RX but attributed it to difference effect compression

All had PEDro Scores of 3 or 4 (1-10)

Hubbard et al JAT 39(1) 88-94 PEDro Scale Physiotherapy Evidence Database (PEDro)

Goal of future Most Cold and Studies Heat Studies

0-2 3 - 4 5 6-8 9-10

0 10 PEDro Score Weak Strong The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials

† There was marginal evidence that ice plus exercise is most effective, after ankle sprain and postsurgery † There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients † Few studies assessed the effectiveness of ice on closed soft-tissue injury, and there was no evidence of an optimal mode or duration of treatment.

Bleakley et al., Am J Sports Med 2004 32 (1), 251-61. ¾Compared 20 minutes ice pack to intermittent (10 minutes 10 minutes off) ice packs ¾The intermittent protocol reduced pain on activity one week after injury ¾No other statistical difference in terms function, swelling and pain at rest ¾Statistical significance vs. clinical significance Compared Heat and cold on acute ankle sprains

Did cold make it Concluded that cold No better or did heat worked better than heat make it Controls worse?????

Hocutt et al. AJSM 1982:10(5)316-9 Comparison of cold, heat and contrast therapy on ankle swelling

¾Subacute Ankle ¾Measurement error was Sprains greater than treatment effect ¾1 Treatment per day ¾No Control Group

5

0 10 PEDro Score Weak Strong

All Three Interventions Increased Limb Volume! Cold had the smallest increase and was deemed most effective

Cote et al. Phys Ther 1988, 68(7) 1072-6 High Voltage Pulsed Current (HVPC)

† Long touted by clinicians as an effective tool in managing pain and and thereby hastening recovery † No evidence that it hastens recovery!!

Michlovitz et al, JOSPT 1988;9,301-304 JOSPT al, et Michlovitz

e dorsiflexion ankle in increase an and edema, pain,

No treatment effect but a tendency toward decreased decreased toward tendency a but effect treatment No

per day per

Did not measure function measure not Did One 30 Minute Treatment Treatment Minute 30 One

for 30 minutes 30 for

minutes HVPS

ICE + HVPS + ICE 30 for ICE ICE followed by by followed ICE

minutes of the injury the of minutes already occurred already

ATC treat within within treat ATC Most swelling has has swelling Most

30 subjects who sustained a grade l or ll Ankle Spain Ankle ll or l grade a sustained who subjects 30

treatment of acute lateral ankle sprains ankle lateral acute of treatment Ice and high voltage pulsed stimulation in in stimulation pulsed voltage high and Ice Michlovitz et al, JOSPT 1988;9,301-304 JOSPT al, et Michlovitz

e

Weak Strong

PEDro Score PEDro

0 10

4

dorsiflexion

decreased pain, edema, and an increase in ankle ankle in increase an and edema, pain, decreased

No treatment effect but a tendency toward toward tendency a but effect treatment No

treatment of acute lateral ankle sprains ankle lateral acute of treatment Ice and high voltage pulsed stimulation in in stimulation pulsed voltage high and Ice ‰Does cryotherapy and e-stim have an added effect? ‰If not, which is more effective ‰Does either modality provide a “clinical effect”

Funded by a Grant from NYSATA What effect does initial treatment have on acute edema formation?

Decrease in Capillary CHVPC Permeability Greater = RX + Effect?

Decreases Metabolic Cryotherapy Activity

Acute Trauma Management 1.1

1

0.9

0.8

Results 0.7

0.6

0.5

0.4 ) g /k L (m

0.3 e m lu o V b im L in e g n a h C 0.2

Treated Limb Untreated Limb 0.1

0 Pr e- 0 30 60 90 120 150 180 210 240 Trauma

Time (min) 1.2

Cryotherapy1 + HVPC had no added treatment effect 0.8 Comparison of Treatment

0.6

0.4

l/kg) CWI e (m 0.2 CHV PC olum CWI+CHV PC hange in V C

0 Pr e- 0 30 60 90 120 150 180 210 240 Trauma

-0.2 Time (min) “Staircase Effect”

bs im ST l L E tro RX R on Limb C ST Volumes E R X us R RX tinuo Con

Trauma 0 30 60 90 120

Time ‰How can we improve the treatment effect? ‰Is more better?

JAT 2003, 38(4) 225-229 Supported by a NYSATA Grant Effects of Continuous Treatment on Edema Formation 1.2 “Golden Minute” for Acute Management 1

0.8

0.6

0.4 Volume(mL/Kg) in Limb Change

Untreated 0.2 Treated

0 Pre-T 0 30 60 90 120 150 180 210 240 Minutes JAT 2003, 38(4) 225-229 How can we optimize our treatments?

Max Untreated Pain &

Edema Intermittent Exercise Continuous Min

Injury Return to Play

Acute Trauma Management Is Amount of Time Treated Related to RX Effect?

Inflammation 100% Cont. HVPC 85% HVPC 1%

Elevation 17% Compression 96% Cryotherapy 6% 0 255075100

Minutes per day expressed as % Effects of electrical stimulation on pain, edema and return to play following ankle sprains in college and professional athletes A Multi-Center Clinical Trial

Frank C. Mendel PhD Michael G. Dolan, MA, ATC John Marzo, MD Dale Fish, PhD, PT Gregory Wilding, PhD

Funded by a grant from The National Football League 50 Acute Lateral Ankle Sprains

Standard RICE Intervention

Treatment Control

Pain Swelling Functional testing RETURN TO PLAY

HVPC Inhibited recovery in HVPC had no effect on recovery of Grade I lateral Ankle Sprains Grade II lateral Ankle Sprains

Effects of HVPC on acute lateral ankle sprains in collegiate and professional football players. Mendel et al. In Review. Effects of HVPC on Return to Play Following Ankle Sprains

‰ Clinical trials often give unexpected ‰ Prospective results ‰ Double Blind ‰ Time of Intervention ‰ Credible Placebo ‰ Does stim retard inhibit healing?

PEDro Score 9-10

0 10 Weak Strong Application of Continuous HVPC in Athletes

Acute Trauma Management Extended Treatment using HVPC BEST PRACTICES: THE TAKE HOME MESSAGE

‰ Limited evidence that RICE and E-Stim hasten recovery ‰ Apply RICE+ other interventions ASAP ‰ Consider Extended Treatment Times and reapply at frequent time intervals (more is sometimes BETTER) † Supervised Rehab supplemented by home therapy Thermotherapy

† Application of superficial and deep heat to improve treatment outcomes Cochrane Review of Superficial Heat and Cold

† Acute and subacute low † Heat wrap therapy reduced pain after 5 days † One trial of 90 participants with acute found that a heated blanket significantly decreased pain † One trial of 100 participants with a mix of acute and subacute low back pain examined the additional effects of adding exercise to heat wrap and found that it reduced pain after 7 days

French et al Spine 2006, 31 (9), pp. 998-1006 Philadelphia Panel Evidence-Based Clinical Practice Guidelines

Low Back Knee Shoulder Neck

ADL’s + TENS + US for calcific Exercise Exercise Tendon lesions Exercise

Thermotherapy is ineffective or no studies to evaluate Effects of heat wraps on skin and muscle temperatures

ThermaCare J& J Back Plaster ABC Warme-Pflaster

↑ temp at 2 cm depth with ↑ temp at skin and greater less sensation of heat sensation of heat

You Decide

Trowbridge JOSPT, 2004,34(9) 549-558 Heat Wraps in the prevention and early treatment of low back DOMS

2 RCT’s

Prevention Treatment

Heat Wrap Control Heat Wrap Cold

Pain Intensity ↓47% at 24 Pain relief was ↑ 138% at 24 hours for heat wrap group hours for Heat Wraps

Self Reported and function decreased 53% & 45% for No differences in self-reported heat wrap group function or disability

Mayer et al. Arch. of Phys. Med 2006 87(10) 1310-1317 Subjects with non-specific low back pain

Do heat wraps worn overnight affect pain, stiffness and ROM?

Heat Wrap worn overnight Control

Overnight use of heatwrap therapy provided effective pain relief throughout the next day, reduced muscle stiffness and disability, and improved trunk flexibility. Positive effects were sustained more than 48 hours after treatments were completed.

Nadler et al. Overnight use of continuous low-level heatwrap therapy for relief of low back pain. Arch of Phys. Med 2003:84(3) 335-342 35 randomized clinical trials that examined US in soft tissue injuries

10 had acceptable methods and included treatment and control groups

2 reported positive outcomes 8 reported no (carpal tunnel syndrome & treatment effect calcific tendonitis of the shoulder)

little evidence that active is more effective than placebo in promoting soft tissue healing.

Robertson and Baker: A review of therapeutic ultrasound: effectiveness studies. Phys. Ther. 2001 81(7)1339-1350 BEST PRACTICES: THE TAKE HOME MESSAGE

‰ Limited evidence that thermotherapy hastens recovery ‰ Moderate evidence that continuous heat therapy decreases pain and improves function in non-specific back pathology ‰ Are these results transferable to other conditions that athletic trainers manage? Thanks for the Invitation

2008 EATA Meeting at Valley Forge Evidence Based Practice

Cold and Heat Therapy

Michael G. Dolan, MA, ATC Professor/Athletic Trainer Director, Sports Medicine Research Laboratory Canisius College Buffalo, NY

2008 EATA Meeting at Valley Forge