Cold Therapy Makes a Comeback

An evidence-based look at cryotherapy in athletic rehabilitation.

Thermal modalities are perhaps the most widely used and readily available of all treatment options for the rehabilitation professional. Undeniably, a hot or cold modality is used either in the physical therapy clinic setting or athletic training room more than any other treatment modality. Further, these heat or cold modalities can be used on people of all ages, activity levels and stage of injury.

Reasons for using thermal modalities are most notably for pain and swelling reduction, as well as improving range of motion. There are a host of options for the clinician to choose from when deciding which type of modality to use, but these options go beyond hot packs and ice bags. Shortwave diathermy, ultrasound and cold compression units are other thermal resources at the clinician's disposal.

Clinical Application of Cold Modalities

By far, the most common cold modality is ice in some form. It's cheap and readily available -- "ice it" has been a timeless instruction after injury. Ice is often used to offset pain, swelling and dysfunction associated with minor athletic trauma.1 Researchers have found that cold leads to pain relief through altered nerve conduction velocity, inhibition of nociceptors, reduction in spasm, reduced metabolic enzyme levels, reduced inflammation and increased pain tolerance.2,3

For acute injuries, it is recommended that ice immersion be used when possible. For example, ice water immersion would be appropriate after an ankle sprain. Knight and Londeree have previously proposed using "cryokinetics," cold application with exercise, as an effective means of treating these injuries.4 It is suggested that the athlete be placed in an ice water immersion bath for three to four minutes, followed by exercise that may include gait training or ankle range-of-motion exercises for a few minutes. The process would then repeat for a total treatment time of 20 minutes.

Cryokinetics could also be used with success in thigh contusions, elbow injuries and wrist injuries. Following the above treatment with compression and elevation to further reduce swelling is advocated for acute injuries. Ice immersion of the elbow is an excellent treatment for pitchers following practices or games. If ice immersion is not possible or available, multiple icing sessions per day following an acute injury are advocated for pain relief if anything, but potentially for swelling reduction when coupled with compression and elevation.

Cold whirlpool is very popular for athletes. This author has experience at the Division I level as well as with Major League Baseball and the National Football League. Athletes routinely get in cold tubs after practices or games to "get their legs back" and help with post-exercise leg soreness. It is believed that the cold immersion results in rapid cooling and subsequent systemic vasoconstriction that will ultimately reduce pain and limit secondary hypoxic injury from the waste products built up with vigorous exercise.

Patterson has found that cold whirlpool immersion can reduce power, speed, range of motion and agility for up to 30 minutes after application.1 Therefore, it is recommended that cold whirlpool only be used after exercise. Contrast therapy has been used for years in athletes, mostly after exercise. The theory behind it is that through contrast, there is vasodilation and vasoconstriction that "pumps" waste products to enhance recovery. Little evidence supports contrast therapy, but it is commonly used.

Ice massage is incredibly effective for treating superficial soft-tissue injuries. It is an excellent choice for Achilles and patellar tendon injuries, medial collateral ligament injuries, "shin splints," and tendonitis of the ankle, knee, elbow and shoulder. In cases of tendonitis, it behooves the clinician to ensure that a true inflammatory condition exists. In cases of chronic tendinopathy, there is no inflammation present. Therefore, ice is not likely to be useful.

Ice massage has also been used with success for analgesia in patients with patellofemoral pain. Ice massage seems be more effective because the application can be focused on a specific spot and analgesia is achieved faster compared to an ice bag.

In cases of deep-muscle contusions, as in a thigh bruise, it is ­suggested that the athlete ice several times a day with the muscle on stretch to minimize the risk of myositis ossificans. Placing the muscle on stretch with ice minimizes the risk of pooling of blood. A complement to the proposed treatment is to place a pad over the area with compressive wrapping to further compress the region and reduce the risk of pooling. Once the acute phase is over, active exercise followed by stretching and ice in the stretched position is advised.

There is little evidence supporting electrical stimulation with ice or compression and ice.5,6 More research is needed on the effects of vasopneumatic devices on swelling compared to compression with compressive wraps. Unfortunately, it is difficult to quantify the placebo effect with modalities. Regardless, it is safe to assume that ice in any capacity is helpful for pain relief.

Cold Therapy Makes a Comeback

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