Is ICE right?

The management of acute soft tissue injuries

Dr Niamh Collins

 Do you recommend Ice?

Do you find Ice beneficial?

Whats 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%

Whats your rationale?

14

12

10

Scientific Reasoning
Experience
Common Sense
Anecdotal
Not Applicable

Number of
responses

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

Whats the evidence?

Search

Soft tissue injury = sprain, strain, contusion, bruise,

haeamtoma, minor injury, ligament and tendon
Ice = ice, cryotherapy, cold, freezing, thermal therapy

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 RCTs
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

Assessing Quality
Quality..
Need to determine the validity effect of bias
Bias is reduced with:
Appropriate randomisation
Blinding
Accounting for missing data

Scoring systems: Jadad & PEDro

Jadad & PEDro

Jadad

PEDro

(Max score 5)

(Max score 10)

Airaksinen et al, 2003. Finland

10

Basur et al, 1976, UK

Cote et al, 1988, USA

Laba et al, 1989, New Zealand

Hocutt et al, 1982, USA

Sloan et al, 1989, UK

Airaksinen et al, 2003. Finland

Population: 74 patients - ? Service attended
Sports related STI < 48 hrs
Exposure: Cold gel vs placebo. 4 x day for 14 days. RCT
Outcome:
Cold therapy - improvement at 7, 14, 28 days in
Pain at rest and movement (p<0.001)
Function (p<0.001)
Benefit - Cold therapy used for 14/7. Well designed study

Sloan et al, 1989, UK

Population: 143 ED patients (116 follow up).Ankle sprains.
Exposure: Cooling anklet with elevation for 30 minutes or
dummy anklet without elevation. RCT
Outcome:
Cold therapy showed trend for improvement Oedema (p=0.07), Injury severity score (p=0.15),
function (p=0.64)
Single application of ice in well designed study

Laba et al, 1989, New Zealand

Population: 30 ED patients referred to physio <48hrs, ankle sprains.
Exposure: Toss coin randomisation. No blinding
Single application of ice x 20 min. Other treatment similar for both.
Outcome: No statistical difference in pain,
pain swelling or function between
groups.

13/30 patients had already used ice prior to study and were included in
both groups.

Cote et al, 1988, USA

Population: 30 patients. Ankle sprains. University Dr. Day 3 post injury
Exposure: Randomised to:
-Cold Treatment,
-Heat Treatment
-Contrast Bath
Ankle volumes measured before and after therapy on Day 3,4,5.
Outcome:
Oedema: all increased oedema with smaller increase in cold group.

Randomisation not described. No blinding.

Baseline group differences and no control.

Hocutt et al, 1982, USA

Population: 53 patients (folow-up 37). Grade 3-4 Ankle sprains.
Exposure: 2 Treatments for 20 min, 1-3 times daily for 3 days.
cooling (whirlpool or ice)
- heat (water or heat pad)
Therapy was started at Day 0, Day 1 or Day 2
Outcome:
Function
Grade 3: COLD - 6 days (Day 0/1), 11 days (Day 2); HEAT - 14.8 days.
Grade 4: COLD - 13.2 days (Day 0/1), 30.4 days (Day 2); HEAT - 33 days.
(P<0.05)

No blinding or randomisation. Subjective scoring by participants. Missing data

Basur et al, 1976, UK

Population: 60 patients. Ankle sprains
Exposure: Cryogel every 4 hrs X 48 hrs & crepe bandage or crepe
bandage alone.
Followed for 14 days.
Outcome:
Combined score for pain, oedema & function - trend in favour of
cryotherapy.
Disability
isability COLD- 9.7 days; CONTROL - 14.8 days

No randomisation, no blinding.
Conflict of interest not stated. Limited statistical analysis.

Animal Studies

Deal et al, 2002, USA

Population: 60 rats with a dorsal microvascular chamber

Exposure: 4 Groups
1) 5 contusion, no ice
3) 15 sham contusion & ice
Ice applied for 20 minutes

2) 15 contusion & ice

4) 15 sham contusion, no ice

Outcome Oedema
Grp 1 had max oedema.
Grp 2 less oedema than grp 1 (p<0.001) but more than grp 4 (p=0.012).

Conclusion Microvascular permeability is increased 300 mins post trauma.

Ice reduces this response.
Group 1 is small. No observer blinding stated.

Dolan MG et al, 1997, USA

Population 16 rats

Exposure Both hind limbs traumatised. Immersion 30 min, rest 30 min.

One limb - 12.8-15.6C. Cool
Control limb 22-25.5C. Room temp

Outcome Oedema
Volume of cold group was smaller than control (p=0.03).

Conclusion
Cold water (12.8-15.6C) curbed oedema formation after blunt trauma

Absolute volume difference of 0.05ml!

Farry PJ et al, 1980, New Zealand

Population 16 piglets

Exposure:
Radio-carpal ligament crushed & stretched. Ice 20 min, rest 1 hour, ice 20 min.
A) 2 - no injury, no ice
B) 4 - no injury, one limb iced
C) 10 - both limbs injured, ice applied to one limb.

Outcome: Oedema - volume/ histological.

Swelling increased with ice (with or without injury)
Histological inflammation (48 hrs) - less with ice.

Conclusion:
Superficial tissues are damaged by cold induced ischaemia.
Ice reduces the microscopic evidence of oedema.

No blinding, no significance testing.

McMaster MC et al, 1979, USA

Population: 30 rabbits

Exposure
1) 10 Controls: Left leg crushed. Room temp.
2) 10 rabbits: Left leg crushed. 5 legs - 30 C, 5 legs - 20 C (one hour).
3) 10 rabbits: Both legs crushed. 10 legs - 30 C, 10 legs - 20C (3 X 1Hr).

Outcome Oedema
Least swelling with cooling to 30C x 1Hr, compared with 20C x 1Hr or control.
Prolonged cooling at 20C and 30C resulted in residual swelling

Conclusion
Benefit from modest cooling for a short period.
Too much cold or prolonged application may be deleterious..

No blinding stated

Where do we stand?

Human studies inconclusive & poor quality

Animal studies suggest modest cooling for brief

periods reduce oedema

Local cooling on post fracture swelling: a controlled study

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

Systematic Reviews

 Clinical evidence base for cryotherapy; 5 sub-questions

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

 Does cryotherapy hasten return to participation?

English language journals 1976-2003. RCTs only.
4 trials. 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. Major limitation is lack of papers obtained.
Hubbard TJ et al, 2004, USA

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

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?