Ice Therapy: How Good is the Evidence?

Ice, compression and elevation are the basic principles of acute soft tissue injury. Few clinicians, however, can give specific evidence based guidance on the appropriate duration of each individual treatment session, the frequency of application, or the length of the treatment program. The purpose of this systematic review is to identify the original literature on cryotherapy in acute soft tissue injury and produce evidence based guidance on treatment. A systematic literature search was performed using Medline, Embase, SportDiscus and the database of the National Sports Medicine Institute (UK) using the key words ice, injury, sport, exercise. Temperature change within the muscle depends on the method of application, duration of application, initial temperature, and depth of subcutaneous fat. The evidence from this systematic review suggests that melting iced water applied through a wet towel for repeated periods of 10 minutes is most effective. The target temperature is reduction of 10 - 15 ^oC. Using repeated, rather than continuous, ice applications helps sustain reduced muscle temperature without compromising the skin and allows the superficial skin temperature to return to normal while deeper muscle temperature remains low. Reflex activity and motor function are impaired following ice treatment so patients may be more susceptible to injury for up to 30 minutes following treatment. It is concluded that ice is effective, but should be applied in repeated application of 10 minutes to be most effective, avoid side effects, and prevent possible further injury.

Key words:

Cryotherapy - soft tissue injury - systematic review.

References

• 1 Baker R J, Bell G W. The effect of therapeutic modalities on blood flow in the human calf.  J Orthop Sports Phys Therapy. 1991;  13 23-27
• 2 Barcroft H, Edholm O G. The effect of temperature on the blood flow and deep temperature in the human forearm.  J Physiol. 1943;  102-105
• 3 Barnes L. Cryotherapy putting injury on ice.  Phys Sportsmed. 1979;  7 130-136
• 4 Basur R L, Shepherd E, Mouzas G L. A cooling method in the treatment of ankle sprains.  Practitioner. 1976;  216 708-711
• 5 Bevan R. The Athletic Trainers Handbook.  Englewood Cliffs, NJ; Prentice Hall 1956: 63-75
• 6 Bilik SE  (ed). The Trainers Bible.  New York; TJ Reed and Co 1946: 257-263
• 7 Bugai R. The cooling, analgesic, and rewarming effects of ice massage on localized skin.  Physical Therapy. 1975;  55 11-19
• 8 Clarke R SJ, Hellom R F, Lind A R. Vascular reactions of the human forearm to cold.  Clin Sci. 1958;  17 165-179
• 9 Collins K, Storey M, Peterson K. Peroneal nerve palsy after cryotherapy.  Phys Sportsmed. 1986;  14 105-108
• 10 Cross K M, Wilson RW, Perrin D H. Functional performance following an ice immersion to the lower extremity.  J Athl Train (Dallas). 1996;  31 113-116
• 11 Curl W W, Smith B P, Marr A, Rosencrance E, Holden M, Smith T L. The effect of contusion and cryotherapy on skeletal muscle microcirculation.  J Sports Med Physical Fitness. 1977;  37 279-286
• 12 Draper D O, Schulthies S, Sorvisto P, Hautala A M. Temperature changes in deep muscles of humans during ice and ultrasound therapy: an in vivo study.  J Orthop Sports Phys Therapy . 1995;  21 153-157
• 13 Drez D, Faust D C, Evans J P. Cryotherapy and nerve palsy.  Am J Sports Med. 1981;  9 256-257
• 14 Ebrall PS, Bales G L. Frost BR. An improved clinical protocol for ankle cryotherapy.  Journal of Manual Medicine. 1992;  6 161-165
• 15 Ebrall P S, Moore N, Poole R. An investigation of the use of infrared telethermography to determine skin temperature changes in the human ankle during cryotherapy.  Chiropractic Sports Medicine. 1989;  3 111-119
• 16 Farry P J, Prentice N G, Hunter A C, Wakelin C A. Ice treatment of injured ligaments: an experimental model.  NZ Med J. 1980;  91 12-14
• 17 Grant A E. Massage with ice (cryokinetics) in the treatment of painful conditions of the musculoskeletal system.  Arch Phys Med. 1964;  45 233-238
• 18 Hartvicksen K. Ice therapy in spasticity.  Acta Neurolog Scand. 1962;  38 79-84
• 19 Hayden C A. Cryokinetics in an early treatment programme.  Am J Phys Ther. 1964;  44 990-993
• 20 Ho S SW, Coel M N, Kagawa R, Richardson A B. The effects of ice on blood flow and bone metabolism in knees.  Am J Sports Med. 1994;  22 537-540
• 21 Hobbs K T. Results of intramuscular temperature changes at various levels after the application of ice.  Sport Health. 1983;  1 15
• 22 Hocutt J E, Jaffe R, Rylander C R, Beebe J K. Cryotherapy in ankle sprains.  Am J Sports Med. 1982;  10 316-319
• 23 Holcomb W R, Mangus B C, Tandy R. The effect of icing with the Pro-Stim Edema Management System on cutaneous cooling.  J Athl Train (Dallas). 1996;  31 126-129
• 24 Hopper D, Whittington D, Chartier J D. Does ice immersion influence ankle joint position sense?.  Physiother Res Int. 1997;  2 223-236
• 25 Job S. A comparative study on the use of ice and intermittent compression in the early treatment of sports injuries.  Physiotherapy in Sport (London);. 1988;  11 4-5
• 26 Johnson D J, Moore S, Moore J, Liver R A. Effect of cold submersion on intramuscular temperature of the gastrocnemius muscle.  Phys Ther. 1979;  59 1238-1242
• 27 Kellett J. Acute soft tissue injuries - a review of the literature.  Med Sci Sports Exer. 1986;  18 489-500
• 28 Kimura I F, Gulick D T, Thompson G T. The effect of cryotherapy on eccentric plantar flexion peak torque and endurance.  J Athl Train (Dallas). 1997;  32 124-126
• 29 Knight K L, Londeree B R. Comparison of blood flow in the ankle of uninjured subjects during therapeutic applications of heat, cold and exercise.  Med Sci Sport Exer. 1980;  12 76-80
• 30 Knight K L. Cryotherapy: theory, technique and physiology 1st ed.  Tennessee; Chattanooga Corporation 1985
• 31 Kowal M A. Review of physiological effects of cryotherapy.  J Orthop Sports Phys Therapy. 1983;  Sept/Oct 66-73
• 32 Laing D R, Dalley D R, Kirk J A. Ice therapy in soft tissue injuries.  N Z Med J. 1973;  78 155-158
• 33 LaRiviere J, Osternig L R. The effect of ice immersion on joint position sense.  Journal of sport rehabilitation (Champaign, Ill.). 1994;  3 58-67
• 34 LaVelle B E, Snyder M. Differential conduction of cold through barriers.  J Adv Nur. 1985;  10 55-61
• 35 Lee J M, Warren M P, Mason S M. Effects of ice on nerve conduction velocity.  Physiotherapy. 1978;  64 2-6
• 36 Lehman J F, Waren C G, Scham S M. Therapeutic heat and cold.  Clin Orthop. 1974;  99 207-245
• 37 Lievens P, Leduc A. Cryotherapy and sports.  Int J Sports Med. 1984;  5 (suppl) 37-39
• 38 Lowden B J, Moore R J. Temperature changes in muscle during cold therapy and following sustained contraction.  Aust J Sports Med. 1977;  9 8-12
• 39 Malone T R, Engelhardt D L, Kirpatrick J S, Bassett F H. Nerve injury in athletes caused by cryotherapy.  J Athl Train (Dallas). 1992;  27 235-237
• 40 Matsen F A, Questad K, Matsen A L. The effect of local cooling on postfracture swelling.  Clin Orthop.. 1975;  109 201-206
• 41 McMaster W C, Liddle S, Waugh T R. Laboratory evaluations of various cold therapy modalities (dog).  Am J Sports Med. 1978;  6 291-294
• 42 McMaster W C, Liddle S. Cryotherapy influence on post traumatic limb oedema.  Clin Orthop. 1980;  150 283-287
• 43 McMaster W C. A literary review on ice therapy in injuries.  Am J Sports Med. 1977;  5 124-126
• 44 Meeusen R, Lievens P. The use of cryotherapy in sports injuries.  Sports Medicine. 1986;  3 398-414
• 45 Merrick M A, Knight K L, Ingersoll C D, Potteiger J A. The effects of ice and compression wraps on intramuscular temperatures at various depths.  J Athl Train (Dallas). 1993;  28 236; 238; 241-245
• 46 Myrer JW, Draper D O, Durrant E. Contrast therapy and intramuscular temperature in the human leg.  J Athl Train. 1994;  29 318-322
• 47 Myrer JW, Measom G, Durrant E, Fellingham G W. Cold and hot-pack contrast therapy: subcutaneous and intramuscular temperature change.  J Athl Train (Dallas). 1997;  32 238-241
• 48 Oliver R A, Johnson D J, Wheelhouse W W, Griffen P P. Isometric muscle contraction response during recovery from reduce intramuscular temperature.  Arch Phys Med Rehabil. 1979;  60 126-129
• 49 Palmer J E, Knight K L. Ankle and thigh skin surface temperature changes with repeated ice pack application.  J Athl Train. 1996;  31 319-323
• 50 Pappenheimer J R, Eversole S L, Solorivera A. Vascular responses to temperature of the isolated perfused hindlimb of the cat.  Am J Physiol. 1948;  155 458
• 51 Quillen WS, Rouillier LH. Initial management of acute ankle sprains with rapid pulsed compression and cold.  J Orthop Sports Phys Therapy. 1982;  4 39-43
• 52 Rimington S J, Draper D O, Durrant E, Fellingham G. Temperature changes during therapeutic ultrasound in the precooled human gastrocnemius.  J Athl Train. 1994;  29 325-327
• 53 Rivenburgh D W. Physical modalities in the treatment of tendon injuries.  Clin Sports Med. 1992;  11 645-659
• 54 Sapega A A, Heppenstall R B, Sokolow D P, Graham T J, Maris J M, Ghosh A K, Chane B, Osterman A L. The bioenergetics of preservation of limbs before replantation.  J Bone Joint Surg (AM). 1988;  70 1500-1513
• 55 Shelbourne K D, Stube K C, Patel D V. Conservative treatment of degenerative joint disease of the knee using cold compression therapy .  Sports exercise and injury (Edinburgh, Scotland). 1996;  2 176-180
• 56 Walton M, Roestenburg M, Hallwright S, Seutherland J C. Effects of ice packs on tissue temperatures at various depths before and after quadriceps hematoma: studies using sheep.  J Orthop Sports Phys Therapy (Baltimore). 1986;  8 294-300
• 57 Waylonis G W. The physiologic effects of ice massage.  Arch Phys Med Rehab. 1967;  48 37-42
• 58 Zemke J E, Andersen J C, Guion W K, McMillan J, Joyner A B. Intramuscular temperature responses in the human leg to two forms of cryotherapy: ice massage and ice bag.  J Orthop Sports Phys Ther. 1998;  27 301-307