Evidence Based Practice Cold and Heat Therapy Michael G. Dolan, MA, - PowerPoint PPT Presentation

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

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 Evidence-Based Practice W here are w e today? W here do w e w ant to go? Large Scale Lots of theories Randomized Clinical Testimonials Trials that examine our treatments and Education & determine our clinical manufacturer driven practice Uninjured human Get Involved! subjects Animal Models Some RCT’s

Top Ten Things an Athletic Trainer Says 1. Put some ice on it

Does it?

I f 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 Cryotherapy 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.

� Compared 20 minutes ice pack to intermittent (10 minutes 10 minutes off) ice packs � The intermittent protocol reduced pain on activity one week after injury � No other statistical difference in terms function, swelling and pain at rest � Statistical significance vs. clinical significance

Compared Heat and cold on acute ankle sprains Did cold make it Concluded that cold better or did heat No 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 � Subacute Ankle � Measurement error was Sprains greater than treatment effect � 1 Treatment per day � No 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 edema and thereby hastening recovery � No evidence that it hastens recovery!!

Ice and high voltage pulsed stimulation in treatment of acute lateral ankle sprains 30 subjects who sustained a grade l or ll Ankle Spain ATC treat w ithin Most sw elling has m inutes of the injury already occurred ICE for 30 ICE + HVPS ICE followed by minutes HVPS for 30 minutes One 3 0 Minute Treatm ent Did not m easure function per day No treatment effect but a tendency toward decreased pain, edema, and an increase in ankle dorsiflexion e Michlovitz et al, JOSPT 1988;9,301-304

Ice and high voltage pulsed stimulation in treatment of acute lateral ankle sprains No treatment effect but a tendency toward decreased pain, edema, and an increase in ankle dorsiflexion 4 0 10 PEDro Score Weak Strong e Michlovitz et al, JOSPT 1988;9,301-304

� 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 Acute Trauma Management

Results 1.1 1 0.9 0.8 ) g k / L m 0.7 ( e m u l o V 0.6 b m i L n i 0.5 e g n a h C 0.4 0.3 Treated Limb Untreated Limb 0.2 0.1 0 P re- 0 30 60 90 120 150 180 210 240 Trauma Tim e (min)

Cryotherapy + HVPC had no added treatment effect Comparison of Treatment 1.2 1 0.8 ) g l/k (m 0.6 e m lu CWI o V in CHVP C 0.4 e g CWI+CHVPC n a h C 0.2 0 Pre- 0 30 60 90 120 150 180 210 240 Trauma -0.2 Time (min)

“Staircase Effect” Control Limbs REST RX Limb REST Volumes X R s u o u n RX i t n o C 30 60 Trauma 0 90 120 Time

� How can we improve the treatment effect? � Is more better? Supported by a NYSATA Grant JAT 2003, 38(4) 225-229

Effects of Continuous Treatment on Edema Formation 1.2 “Golden Minute” for Acute Management 1 Change in Limb Volume(mL/Kg) 0.8 0.6 0.4 0.2 Untreated Treated 0 Pre-T 0 30 60 90 120 150 180 210 240 JAT 2003, 38(4) 225-229 Minutes

How can we optimize our treatments? Max Untreated Pain & Edema I ntermittent Exercise Continuous Min Return to Play I njury Acute Trauma Management Acute Trauma Management

Is Amount of Time Treated Related to RX Effect? Inflammation 100% Cont. HVPC 85% HVPC 1% Elevation 17% 96% Compression Cryotherapy 6% 0 25 50 75 100 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 had no effect on recovery of HVPC Inhibited recovery in Grade II lateral Ankle Sprains Grade I 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? 9-10 PEDro Score 0 10 Weak Strong

Application of Continuous HVPC in Athletes Acute Trauma Management 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 back pain � Heat wrap therapy reduced pain after 5 days � One trial of 90 participants with acute low back pain 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 disability and No differences in self-reported function decreased 53% & 45% for function or disability heat wrap group 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