Cold Therapy: Ice is nice, but other cryotherapy options abound

Simple ice. For hard-core athletes, there's nothing like it to prepare an injury for pre-game battle and to relieve swollen tissues after everyone has left the field. But that hasn't stopped more than a dozen manufacturers from trying to recreate ice or redefine how it is used. Making a better ice pack or a better way to keep cold therapy where it's needed is at least a $50 million business in the U.S. alone. No wonder there seems to be a new cold therapy product around every corner.

Innovation, however, is a matter of perspective. Some products on the market are considered interesting and convenient alternatives to simple ice, whether for an injury or postsurgical use. From physical therapists to certified athletic trainers and orthopedic surgeons, everyone has their own methods for how they apply cold therapy to injuries or postoperative wounds. Even some comparative studies report results that are polar opposites.

What is a practitioner to do? Stick with the basics of RICE (rest, ice, compression, elevation) and the modalities for applying cold therapy become self-evident, according to practitioners. It all depends on how active and how resourceful the patient or athlete is.

And while everyone might wish there was a better - dripless - way to apply the basic ice cube, experts are most apt to find fault with inappropriate use of cold therapy by practitioners.

"We have a very simple device, but its simplicity makes many people overlook some of the principles they could be using with it and as a result of that, they don't get the maximum benefit," said Kenneth L. Knight, PhD, ATC, professor of athletic training at Brigham Young University in Provo, UT. "Many times, the therapy is not done correctly."

"The key," said David Reynolds, PT, ATC, a practitioner with East Suburban Sports Medicine Center in North Huntington, PA, "is getting cold on the person, getting it on consistently, and leaving it on long enough so it has a true physiological effect. Whether you use a 50 cent product or a $2000 product, adhering to the protocol of using the ice is more important than how fancy the device is."

Knight, the author of Cryotherapy in sport injury management (Champaign, IL: Human Kinetics, 1995), feels many vendors are coming up with devices to cash in on this market.

"Many of the devices I don't see as improving too much on the basic ice cube," he said.

On the other hand, patient convenience and compliance is an issue.

"You'll not get as good a performance as the ice cube, but an ice cube unused isn't any good either," he said.

Efficacy and patient compliance are the reasons Evan Ekman, MD, chooses continuous cold flow therapy instead of old-fashioned ice. He is an assistant professor of orthopedic surgery and director of the University of South Carolina's Sports Medicine Center in Columbia.

"(With) something that is under a dressing for either an acute injury or in a postoperative setting, I don't have to worry about ice on the knee to maintain a cold temperature," he said. "I also can intimately fine-tune the temperature of the unit I am using."

Ekman uses a continuous cold flow therapy unit that monitors the temperature at the pad/skin interface, he said. The temperature of the skin feeds back to the unit to adjust the temperature of the pad.

"To me, continuous cold therapy is not a technological breakthrough, but it is a significant advancement from the patient's perspective. It increases compliance, patient satisfaction, and ultimately, the efficacy of cold therapy," he said.

To control postoperative pain, Randall Robbins, MD, of Oak Ridge, TN, prefers an ice pack connected to the continuous-flow cold therapy pump.

"I chose that because it gives both compression and cryotherapy. The disadvantage to new products is they don't give a constant temperature regulation. If water heats up, then the area gets warm. I don't put anything between the skin and the cryo unit. I put steri-strips over the wound, one 4 x 4 inch gauze pad and tape, then the cryo unit over the shoulder. I haven't had any problem with ice burns with the ice pack," Randall said.

On the field, however, the continuous cold therapy unit is not necessarily the most practical method of applying cold.

"We use mostly ice," said Jennie Stone, ATC.

Stone is senior manager for clinical programs in the division of sports medicine for the U.S. Olympic committee in Colorado Springs, CO.

"In the athletic world, there're a lot of reasons for that. Oftentimes, you have to mix up beverages and drinks, so you need an ice machine anyway. Even if you use a reusable product, you can't get rid of your ice machine."

Another benefit of ice is that it can be applied before a treatment or a sport activity, said Bob Gailey, PhD, PT, professor of physical therapy at the University of Miami School of Medicine in Florida. In Gailey's small private practice, he works with geriatric patients and amputees, including some Paralympic athletes.

"It can be applied during the activity, when a player comes off the field, and after the game," he said. "(Ice) can be found in a home, in a trainer's kit, on the field, in a rehab center. It's incredibly mobile. You can wrap someone up in an ice bag with no loss of dollars. One of the simplest forms of ice is a bag of frozen peas. It forms nicely around the ankle or elbow. You put it on for 20 minutes, put it back in the freezer and use it over and over again. It's simple, cheap, and just as effective as more expensive equipment."

Innovative techniques for applying ice, Gailey added, include a variety of cuffs, sleeves, and cold garments that allow for application of ice completely around the shoulder, ankle or knee.

At Robert Forster Physical Therapy in Santa Monica, CA, bagged ice is the winner.

"We use ice cubes and water in bags that are rubber on the inside and cloth on the outside," Robert Forster, PT. His clinic specializes in sports medicine and spine, back, and neck care. He also works with some elite athletes.

"Research shows clearly that type of mixture, with compression, will get to the deepest tissues. The gel packs are often very cold when they come out of the freezer and people get frostbite. Ice application is about taking heat out, but only (while it) is melting. The gel packs warm up too quickly."

There is a place for packs, Stone said.

"We use them the most when we are out of the country and are concerned about the water source. We try to keep athletes away from water that might be contaminated. They (packs) work fine in that environment. But when you start looking at cost ratios, they are not as cost-effective as ice," she said.

Many of the commercial packs are directed at recreational athletes.

"That's a huge market," Stone said. "If you sell one cold pack to every runner in the U.S., that's a lot. Recreational athletes aren't as tolerant of ice. If it leaks and soaks your couch for the next three days, most people aren't real happy."

Unhappy with basic cold therapy was how James M. Fox, MD, felt after his own knee injury.

"I've gone through the frozen peas and the crushed ice in a plastic bag," said Fox, an orthopedic surgeon at the Southern California Orthopedic Institute in Los Angeles. "I've put the ice cubes in a plastic bag and an Ace bandage and wrapped it around my leg. It was a very good experience to have the ice bag open up on the bed and drip all over my sheets."

Thus began his personal interest in postoperative cryotherapy.

The survey said...

In 1998, Fox researched the use of a continuous-flow cold therapy unit versus a reusable, strap-on ice wrap versus no cold therapy. During a three-month period, his research measured the responses of 25 postop patients using each modality for a total of 75 patients.

In the study, which he has submitted for publication, he did the outpatient ACL reconstruction surgery. The average patient age was 26. Patients reported their level of pain every few hours using a Visual Analog Scale.

The results failed to show a significant difference in treatment from one cold therapy modality to another. Fox saw no statistical difference among the groups with respect to such parameters as use of pain medication and self-rating of degree of pain, he said.

"Unfortunately, it had to be an informed consent study," Fox said. "We had to say to people: You might not get any cold. Are you willing to still participate? They had to self-select themselves into an 'I can handle it' kind of group."

For patient comfort and swelling, he added, the results were equal between the two (cold) systems.

"At this point in my practice, I routinely offer patients the cold wrap. The patients are happy," Fox said.

Patients receive the same cold therapy benefits from a cold wrap as from costly equipment and it is what Fox refers to as "phone call effective:" He receives fewer phone calls from patients complaining that the equipment has leaked all over the bed.

On the opposite end of the product-preference spectrum is F. Alan Barber, MD, an orthopedic surgeon at Plano Orthopedic and Sports Center in Plano, TX. Results of his studies support continuous flow cold therapy as the modality of choice for postop care. He compared continuous-flow cold therapy to crushed ice and to no ice. The studies included 125 patellar tendon autograft patients.

"We found that the ice was actually worse than doing nothing," Barber said. "The continuous flow cold therapy was best of all. It provided less pain, more motion postoperatively, and less need for narcotics. On days two and three it made a big difference. My conclusion was that it enhanced postop rehab to use a continuous flow cold therapy device."

Barber is working on a new study to compare gel packs, crushed ice, and a product similar to a gel pack that has the ability to maintain a cold temperature up to two hours. It was introduced in April 1999 and is being targeted at the postop market. This will be the first clinical study of the product, which can also be heated in the microwave. Barber expects the results to be available early in 2000.

Another study that should be completed in the first quarter of this year is being conducted by Ekman at the University of South Carolina's Sports Medicine Center.

"We're trying to find the optimum safe temperature at which a continous cold temperature unit should be set," he said.

The study has two main elements: results on healthy human volunteers and results on patients who have undergone ACL reconstruction. Continuous cold therapy units will be used on healthy volunteers wearing a postsurgical dressing on their knees, and the skin temperature beneath the dressing will be monitored every 30 minutes to assess the effect of the cold therapy. Intraarticular temperature will be measured in the postreconstruction patients via a probe in the surgical drain.

"We're trying to find out, ultimately, at a specified temperature on the unit, what is the temperature of the skin in the presence of a surgical dressing and the temperature of the joint," he said. "If the temperature isn't as cold as we think, perhaps we have to increase the temperature of the unit to optimize efficacy in the joint. (But) we want to be sure we don't get the skin too cold."

In his practice Ekman sees athletes, active people, laborers, and geriatric patients, he said.

"Sometimes we have sort of a peripheral desire to get an athlete back to healthy more quickly," he said. "But swelling and pain are equally important to the athlete, the nonathlete, the 10 year old, and the 90 year old."

The good news about how to apply cold therapy, Gailey said, is that there isn't one best way.

"Today, the clinician has multiple options to find out what is easier in a particular environment," he said.

Written by Andria Segedy. Featured in Biomechanics Magazine, Feb. 2000.