Is ICE right?

The management of acute soft tissue injuries

Dr Niamh Collins

• Do you recommend Ice?

• Do you find Ice beneficial?

• What’s your rationale?

• Have you questioned the evidence?

• Have you read any supportive literature?

Do you recommend Ice?

7%

10%

20%
Always
Frequently
Occasionally
Never
63%

Is Ice beneficial? 56% 7% Yes Unsure No Not Applicable 7% 30% .

What’s your rationale? 14 12 10 Scientific Reasoning Experience Common Sense Anecdotal Not Applicable 8 Number of responses 6 4 2 0 1 .

Have you questioned the evidence? 17% 17% Frequently Occasionally Never 66% .

Have you read any supportive literature? 18 16 14 12 Yes No Unsure 10 Number of Responses 8 6 4 2 0 1 .

What’s the evidence? .

Search • Soft tissue injury = sprain. bruise. minor injury. thermal therapy . cryotherapy. ligament and tendon • Ice = ice. cold. strain. contusion. freezing. haeamtoma.

.

Outcomes? • Temperature? • Muscle enzyme levels? • • • • Pain Function Swelling (oedema) Return to activity .

• Medline (1966+) • EMBASE • Cochrane Library • Google Scholar • Citation Tracking .

• A lot of papers – but not relating to my ED patient • Very little evidence! • Broaden criteria – Include all trials. not just RCT’s – Include animal and human studies .

• 66 potential papers identified .Difficulty sourcing some! • 6 Human Trials • 4 Animal Trials • 2 Systemmatic Reviews Some others of interest .

. • Need to determine the validity – effect of bias • Bias is reduced with: – Appropriate randomisation – Blinding – Accounting for missing data • Scoring systems: Jadad & PEDro .Assessing Quality… Quality….

USA 1 2 Sloan et al. 1988. 2003. Finland 5 10 Basur et al.Jadad & PEDro Jadad PEDro (Max score 5) (Max score 10) Airaksinen et al. New Zealand 3 3 Hocutt et al. UK 5 8 . 1989. 1982. UK 0 2 Cote et al. USA 2 4 Laba et al. 1989. 1976.

Airaksinen et al. Well designed study .Cold therapy used for 14/7. 14. 4 x day for 14 days. 2003. 28 days in Pain at rest and movement (p<0.? Service attended Sports related STI < 48 hrs Exposure: Cold gel v’s placebo.improvement at 7.001) Benefit .001) Function (p<0. RCT Outcome: Cold therapy . Finland Population: 74 patients .

15). 1989.Sloan et al.07). UK Population: 143 ED patients (116 follow up). Exposure: “Cooling anklet” with elevation for 30 minutes or dummy anklet without elevation.Ankle sprains. Injury severity score (p=0. function (p=0.64) Single application of ice in well designed study . RCT Outcome: Cold therapy showed trend for improvement Oedema (p=0.

ankle sprains. New Zealand Population: 30 ED patients referred to physio <48hrs. Outcome: No statistical difference in pain. pain swelling or function between groups. . 1989. Other treatment similar for both.Laba et al. 13/30 patients had already used ice prior to study and were included in both groups. Exposure: Toss coin randomisation. No blinding Single application of ice x 20 min.

4. Randomisation not described. Ankle sprains. University Dr. . -Heat Treatment -Contrast Bath Ankle volumes measured before and after therapy on Day 3.5.Cote et al. Outcome: Oedema: all increased oedema with smaller increase in cold group. USA Population: 30 patients. 1988. No blinding. Day 3 post injury Exposure: Randomised to: -Cold Treatment. Baseline group differences and no control.

2 days (Day 0/1). – cooling (whirlpool or ice) . 1-3 times daily for 3 days. 30. Grade 3-4 Ankle sprains. 11 days (Day 2).4 days (Day 2).Hocutt et al.8 days. Grade 4: COLD . Subjective scoring by participants.13. Day 1 or Day 2 Outcome: Function Grade 3: COLD .6 days (Day 0/1).14. (P<0. HEAT .heat (water or heat pad) Therapy was started at Day 0. 1982.05) No blinding or randomisation. Exposure: 2 Treatments for 20 min. USA Population: 53 patients (folow-up 37). HEAT . “Missing” data .33 days.

7 days.trend in favour of cryotherapy. .14. Conflict of interest not stated. 1976. Ankle sprains Exposure: Cryogel every 4 hrs X 48 hrs & crepe bandage or crepe bandage alone. Limited statistical analysis.Basur et al. UK Population: 60 patients. Disability isability COLD. Outcome: Combined score for pain. CONTROL .9.8 days No randomisation. no blinding. Followed for 14 days. oedema & function .

Animal Studies .

Group 1 is small.001) but more than grp 4 (p=0.012). Ice reduces this response. No observer blinding stated. Grp 2 less oedema than grp 1 (p<0. no ice 3) 15 sham contusion & ice Ice applied for 20 minutes • 2) 15 contusion & ice 4) 15 sham contusion. .Deal et al. no ice Outcome – Oedema Grp 1 had max oedema. • Conclusion Microvascular permeability is increased 300 mins post trauma. 2002. USA • Population: 60 rats with a dorsal microvascular chamber • Exposure: 4 Groups 1) 5 contusion.

Room temp • Outcome Oedema Volume of cold group was smaller than control (p=0.6°C) curbed oedema formation after blunt trauma Absolute volume difference of 0.12. One limb . rest 30 min.03). 1997. • Conclusion Cold water (12.Dolan MG et al. Immersion 30 min. Cool Control limb – 22-25.8-15. USA • Population 16 rats • Exposure Both hind limbs traumatised.8-15.05ml! .6°C.5°C.

• Outcome: Oedema . one limb iced C) 10 . . ice applied to one limb.less with ice.both limbs injured. No blinding. Swelling – increased with ice (with or without injury) Histological inflammation (48 hrs) . rest 1 hour.no injury. Ice 20 min.Farry PJ et al. 1980. no ice B) 4 . ice 20 min. Ice reduces the microscopic evidence of oedema.no injury. • Conclusion: Superficial tissues are damaged by cold induced ischaemia.volume/ histological. A) 2 . New Zealand • Population 16 piglets • Exposure: Radio-carpal ligament crushed & stretched. no significance testing.

• Outcome Oedema Least swelling with cooling to 30°C x 1Hr. 10 legs . 5 legs . 10 legs . Room temp.. 1979. 2) 10 rabbits: Left leg crushed.30° C. USA • Population: 30 rabbits • Exposure 1) 10 Controls: Left leg crushed. Too much cold or prolonged application may be deleterious.30° C. 3) 10 rabbits: Both legs crushed.20°C (3 X 1Hr). Prolonged cooling at 20°C and 30°C resulted in residual swelling • Conclusion Benefit from modest cooling for a short period.20° C (one hour). No blinding stated .McMaster MC et al. 5 legs . compared with 20°C x 1Hr or control.

Where do we stand? .

Human studies – inconclusive & poor quality Animal studies – suggest modest cooling for brief periods reduce oedema .

limbs cooled to 20-25°C x 24 hrs. Matsen et al. An inverse linear relationship exists between temperature and soft tissue oedema. Clin Orthop.limbs cooled to 10°C x 6 hrs No significant swelling .Local cooling on post fracture swelling: a controlled study Rabbits: Tibial fractures cooled to 5-25 °C for 6 or 24 hrs.limbs cooled to 5-15 °C x 24 hrs No significant swelling . Significant swelling . (1975) .

Systematic Reviews .

• Clinical evidence base for cryotherapy. PEDro scoring. Human studies. Bleakley C et al. • Outcome measures. ROM and function. Non specific conclusion due to the breath of the clinical question. • High quality studies needed to ensure evidence based practise. 5 sub-questions • Literature search – thorough. Ireland . 5 soft tissue. • Broad inclusion criteria – trauma & post operative RCT’s. pain. swelling. 2004. range 2-5/10. 17 surgery. • 22 studies.

RCT’s only. PEDro Scores 2-4/10 • Cryotherapy soon after injury may speed up return to work or sports • Well designed systematic review with focussed clinical question. 2004. • 4 trials. Hubbard TJ et al. USA .• Does cryotherapy hasten return to participation? • English language journals 1976-2003. Major limitation is lack of papers obtained.

provides analgesia for muscle spasm. Numbers involved in studies are low and comparisons are difficult. while useful. Olson & Stravino (1972) Review 1950’s and 60’s papers. is probably confounded by other first aid measures. Use physiological and clinical studies to suggest that cryotherapy may decrease haemorrhage & oedema. .Other evidence Meeusen & Lievens Conclude: cryotherapy.

In conclusion • No human studies showing definite benefit • No human studies showing major harm • Animal studies: – modest and brief cooling may reduce oedema .low temperatures and prolonged cooling damage tissue .

If ICE was a drug – would you use it? .

Why avoid Ice? of ice? 25 20 Unproven Unnecessary Burdensome Hazardous Not Applicable 15 Number of responses 10 5 0 1 .

But ……… • Ice is universally accepted • Further studies are unlikely – not commercial • Side effects – cost (minimal) – inconvenience (on the patient not the Dr) – tissue injury (frost bite. nerve injury) occasional • .

What will you recommend? .