Per crioterapia ( in riabilitazione ) si intende un tipo di terapia fisica mediante il freddo : con la diminuizione della temperatura cutanea e dei tessuti sottostanti così indotta , si ottiene attraverso un potente effetto analgesico ed antiinfiammatorio un' anestesia temporanea della parte sottoposta al trattamento , muscolo , tendine o articolazione.

La bassa temperatura , e la velocità con la quale essa si instaura , delle zone sottoposte all'azione del freddo dipende da diversi fattori : il metodo usato , la temperatura di partenza , il tempo di permanenza sulla pelle , lo spessore del grasso sottocutaneo.Maggiore è il tempo di applicazione più in profondità esso agisce ; nel muscolo la temperatura può essere ridotta fino a quattro centimetri in profondità , in quanto il muscolo è un tessuto che contiene acqua e pertanto diventa un eccellente conduttore di freddo, al contrario del grasso che è idrofobo.

Indicazioni cliniche

attualmente la crioterapia trova le sue elettive applicazioni nella patologia dell'apparato muscolo-tendineo sopratutto nei traumi diretti o indiretti determinatisi durante la pratica dell'attività sportiva ( protocollo RICE ).In fase acuta l'ipotermia viene impiegata in virtu' delle sue proprietà antimetaboliche , algosedative ed antispastiche .Nelle riacutizzazioni di quadri flogistici cronici articolari , muscolari e tendinei , essa otiiene buoni risultati per l'azione antiinfiammatoria e per gli effetti anestetico e miorilassante.

Nei traumi acuti il trattamento del freddo è utile dal primo giorno a due settimane.( secondo alcuni la crioterapia sarebbe efficace anche per 4-5 settimane )

Il pericolo di congelamento della parte trattata è una possibilità remota, ma esiste il rischio di una ustione da freddo se esso non viene usato correttamente ; si consigliano max 20 minuti ogni ora ( secondo il protocollo classico ) da ripetere più volte ad intervalli regolari.

Secondo altri il trattamento a intermittenza ( 10 minuti ghiaccio , 10 minuti senza ) darebbe risultati maggiori , in quanto la pausa permetterebbe alla pelle di ritornare alla temperatura di partenza ( con meno complicazioni ) mentre i tessuti immediatamente sotto conserverebbero il freddo.

L’applicazione del freddo nei traumi può essere fatto anche in combinazione con il bendaggio elastico e compressivo ;sicuramente abbinando la compressione ( Compression ) all'azione del ghiaccio ( Ice ) ,tempi fondamentali del protocollo RICE , la guarigione dai traumi dello sport viene notevolmente accellerata.La compressione inoltre favorisce la ripresa funzionale perché i recettori del sistema propriocettivo risentono dell’edema e dell’immobilizzazione creando una situazione di instabilità funzionale.

Meccanismo d’azione

L'azione del freddo si esplica a diverso livelli con diversi effetti .

Ricordiamo i segni classici dell'infiammazione : rubor , calor , dolor e functio lesa.L' azione del freddo blocca tutti e quattro segni .

antiinfiammatorio ( azione anti rubor e calor )

Il freddo determina un'immediata vasocostrizione locale , con conseguente riduzione del flusso ematico direttamente proporzionale alla differenza di temperatura tra la parte trattata e la sorgente del freddo.La vasocostrizione controlla il rigonfiamento edematoso dell'area interessata.Segue un'azione antiistaminica che inibisce l'apertura ( istamino-indotta ) dei pori capillari , attraverso i quali avviene la fuoriuscita delle proteine plasmatiche.Pertanto il freddo riducendo l'accumulo delle sostanze osmoticamente attive impedisce l'estensione del danno tissutale preservando le cellule dalla necrosi ipossica.Viene quindi accellerata la rimozione dei detriti tissutali ad opera dei macrofagi.

analgesico-anestetico ( azione anti dolor )

Questo effetto del freddo si esplica a livello locale e centrale.Topicamente il freddo ottiene un incremento della soglia al dolore tramite un'inibizione esercitata sui recettori algogeni e sulle relative fibre afferenti.Con la diminuizione della temperatura scompare prima il tatto lieve e la percezione del dolore superficiale e poi il tatto profondo e la percezione del dolore profondo.

A livello centrale l'effetto analgesico del freddo viene spiegato con la teoria del "gate control":gli stimoli termici sulla pelle ostacolano la trasmissione e la recezione degli impulsi dolorosi e tale effetto avrebbe luogo a livello delle corna posteriori del midollo spinale.

effetto antimetabolico ( azione anti functio lesa )

il freddo rallenta l'attività metabolica tissutale , limitando il consumo d'ossigeno che decresce parallelamente alla caduta della temperatura corporea ; l'ipotermia mette le cellule in uno stato di torpore metabolico , rallentandone alcune attività enzimatiche non essenziali e quindi consententendo loro di resistere piu' a lungo all'ischemia.Normalmente l'ipossia viene tollerata per tempi molto diversi dai vari organi .Si va dalle due ore del tessuto epatico a 3-5 minuti del sistema nervoso.Le strutture osteomuscolari resistono a lungo alla mancanza di ossigeno ma un ridotto apporto di esso , durante le ore successive ad un trauma , può accentuarne lo squilibrio metabolico e quindi estendere il danno tissutale.Il freddo constrasta efficacemente questi fenomeni di "functio lesa "

effetto antispastico

il muscolo raffreddato progressivamente manifesta un graduale rilassamento .L'azione antispastica si spiega con la riduzione dell'imput sensoriale e l'inibizione dei riflessi da stiramento.L'effetto antalgico , in un punto qualsiasi della catena neurosensoriale , interrompe il circolo vizioso creatosi e , consentendo al muscolo di rilassarsi esercita un'azione antispastica.

Metodiche di Crioterapia

La comune borsa del ghiaccio ( ice bag ) è sicuramente lo strumento crioterapico piu' diffuso e tra i piu' efficaci : non dovrebbe mai mancare nella borsa del pronto soccorso ai bordi del campo sopratutto perle sue capacità di essere modellata sulle articolazioni
le immersioni in vasche contenenti acqua raffreddata con ghiaccio ( sopratutto impiegate per il trattamento degli arti o di loro segmenti ).Sono oggi molto in voga tra i giocatori di rugby che le fanno in grande vasconi dopo ogni partita.Oltre ad avere un effetto analgesico e il freddo può anche avere un effetto miorilassante anestetizzando le terminazioni nervose .
bombolette spray ( inferiori all'impacco di ghiaccio ) Le bombolette spray sono molto famose in tutti i nostri campi di gioco , dal calcio alla pallacanestro.
Sono quasi sempre composte da fluorometano , sostanza non infiammabile e non tossica che viene confezionato in una bomboletta sotto pressione. Prima del suo utilizzo la bomboletta deve essere capovolta su se stessa, e premendo su di una valvola verrà emesso lo spray ad una certa distanza di sicurezza dalla cute per non provocare lesioni da congelamento.La bomboletta deve essere tenuta con una inclinazione di 30° ad una distanza dalla pelle di 30 40 cm.
Lo spray si passa su tutta la lunghezza del muscolo e viene applicato 2 - 3 volte durante l’intervento sul campo; non bisogna assolutamente sovraccaricare il muscolo interessato o l’articolazione ; dopo qualche minuto è opportuno fare dei movimenti di allungamento muscolare .Non bisogna spruzzare verso gli occhi, naso, bocca e orecchie.
Negli ultimi anni sono divenuti d'uso comune i "cold gel pack " , sacchetti in polivinile contenenti una sostanza gelatinosa che , una volta raffreddata , mantiene a lungo la bassa temperatura ; tali strumenti possono essere utilizzati piu' volte , fintanto che l'involucro in vinile rimane intatto.
Refrigeranti chimici : speciali sacchetti monouso formati da due reattivi separati fra loro ; l'attivazione viene effettuata "spezzando " l'apposito separatore interno.Le due sostanze , reagendo tra loro , determinano un rapido e consistente abbassamento della temperatura.Bisogna fare attenzione a non rompere la busta esterna perchè il contatto con le sostanze contenute con la pelle può provocare ustioni .

La crioterapia è controindicata quando sono presenti

ipersensibilità al freddo,

disturbi sensitivi,

ferite aperte ,

vesciche cutanee

e disturbi alla circolazione arteriosa

acrocianosi e fenomeno di Raynaud

Il massaggio con ghiaccio,

Il massaggio o l’applicazione del ghiaccio può essere fatta con del ghiaccio già predisposto in un bicchiere o altro recipiente dove si potrebbe immerge un 'abbassalingua come manico facile da maneggiare .Bisogna frizionare il ghiaccio su di un’area dai 10 ai 15 cm per un tempo che varia dai 5 ai 10 minuti. Si percepisce una sensazione di freddo, di bruciore, di dolore e torpore fino a raggiungere uno stato analgesico ; contemporaneamente bisogna fare degli esercizi di allungamento muscolare, il cosiddetto streching.

I crioultrasuoni.

Questa terapia consiste in uno strumento simile ai comuni ultrasuoni, ma con la differenza che la testina si presenta con un involucro di ghiaccio . Chi non possiede questa macchina, può sostituire il trattamento utilizzando una borsa di ghiaccio posta sulla parte da trattare 5-10 minuti prima degli ultrasuoni.

Criocinetica

È una tecnica molto valida che usa la combinazione del freddo con immersione in acqua con ghiaccio, accompagnata da una serie di esercizi graduali e progressivi. La parte lesionata viene immersa ferma per venti minuti e poi si iniziano dei movimenti semplici senza carico del peso corporeo per diventare progressivamente più complessi e con carico del peso . Con questa tecnica che va ripetuta almeno 3-4 volte la riabilitazione può essere iniziata molto prima.

La crioterapia generalizzata

è una terapia nuova e di molto efficace su svariate malattie reumatiche, inventata e messa a punto in Giappone e poi diffusa dal 1980 in Europa. In Germania è stata introdotta nel 1985 in alcune cliniche, soprattutto reumatologiche.

Oltre che nella fibromialgia, la sua efficacia è stata dimostrata in svariate patologie reumatiche, infiammatorie, non infiammatorie o autoimmuni, nelle connettiviti, nella bronchite spastica; ed è sperimentata (anche se non ancora studiata) in molte altre malattie come neurodermiti, psoriasi, nevralgie del trigemino, asma bronchiale, cefalee croniche, immunodeficienze), come trattamento coadiuvante nel recupero dopo traumi sportivi

La cabina del freddo è uno spazio di circa 2-4 metri quadrati che viene raffreddato a temperature fra i - 70° e i - 80°. Oltre alla temperatura è regolabile anche l’aerazione (“wind chill”), dunque l’azione del freddo sulla pelle può essere regolato individualmente. L’aggiunta dell’aerazione consente di abbassare ulteriormente la temperatura percepita soggettivamente fino a oltre - 100°.

All’inizio il trattamento dovrebbe essere effettuato più volte consecutive, dunque sono efficaci uno o più trattamenti quotidiani.

La riduzione o l’azzeramento del dolore si verifica quasi subito (dopo circa mezzo minuto) e offre alla maggioranza dei pazienti una libertà dal dolore immediata e piuttosto duratura. A questo si aggiunge un miglioramento funzionale delle articolazioni e un aumento del benessere generale. Molti pazienti lasciano la cabina del freddo del tutto liberi dal dolore Poco dopo il trattamento si percepisce una sensazione di calore diffuso. Questo primo effetto analgesico dura da 2 a 6 ore per poi scomparire gradualmente. Per molti pazienti che vengono a fare la crioterapia nelle ore pomeridiane (per esempio dopo il lavoro) questo significa già un sonno notturno indisturbato

La mobilità accresciuta e la libertà dal dolore dopo la crioterapia può essere utilizzata sopratutto per fare esercizi di ginnastica riabilitativa, in particolare di allungamento e stretching.

A lungo termine, cioé dopo una serie di trattamenti, la maggioranza dei pazienti raggiunge un miglioramento davvero notevole della sintomatologia: dopo un trattamento di 6 settimane il 90 % dei pazienti riferisce miglioramenti del dolore spontaneo e conseguente al movimento. Cira il 70% dei pazienti, dunque, può di conseguenza ridurre di molto l'assunzione di farmaci antidolorifici.

Si verifica una serie di ulteriori effetti positivi: per esempio un miglioramento della respirazione. Il volume respiratorio aumenta (aumento della capacità respiratoria), si riduce il broncospasmo, aumenta l'ossigenazione del sangue e diminuisce il contenuto sanguigno di anidride carbonica. Si verifica anche una serie di effetti positivi sulla pelle. In particolare si apprezza la riduzione della tensione cutanea nelle psoriasi e nelle neurodermitis.

Crioterapia dermatologica

La crioterapia con azoto liquido è una metodica dermatologica indicata per il trattamento non invasivo di lesioni dermiche di varia natura , da quelle virali a quelle neoplastiche.L'azoto liquido non è altro che "aria" raffreddata alla temperatura di 196 gradi sotto lo 0. Il freddo così erogato, congela il tessuto patologico formando dei cristalli di ghiaccio intracellulari che provocano la lisi e shock termico della cellula. Le due metodiche più utilizzate sono quella spray e quella a contatto.

Vedi le altre terapie fisiche

laserterapia

ionoforesi

ultasuonoterapia

radarterapia

letteratura internazionale sulla crioterapia

Int J Sports Med. 2001 Jul;22(5):379-84.

Ice therapy: how good is the evidence.

Mac Auley DC Institute of Postgraduate Medicine and Health Science University of Ulster, Northern Ireland. DC.Macauley@ulst.ac.uk

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 degrees C. 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.

J Athl Train. 2004 Sep;39(3):278-279

Does Cryotherapy Improve Outcomes With Soft Tissue Injury? Hubbard TJ, Denegar CR.

Pennsylvania State University, University Park, PA.

REFERENCE: Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sport Med. 2004; 32:251-261. CLINICAL QUESTION: What is the clinical evidence base for cryotherapy use? DATA SOURCES: Studies were identified by using a computer-based literature search on a total of 8 databases: MEDLINE, Proquest, ISI Web of Science, Cumulative Index to Nursing and Allied Health (CINAHL) on Ovid, Allied and Complementary Medicine Database (AMED) on Ovid, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effectiveness, and Cochrane Controlled Trials Register (Central). This was supplemented with citation tracking of relevant primary and review articles. Search terms included surgery,orthopaedics,sports injury,soft tissue injury,sprains and strains,contusions,athletic injury,acute,compression, cryotherapy,ice,RICE, andcold. STUDY SELECTION: To be included in the review, each study had to fulfill the following conditions: be a randomized, controlled trial of human subjects; be published in English as a full paper; include patients recovering from acute soft tissue or orthopaedic surgical interventions who received cryotherapy in inpatient, outpatient, or home-based treatment, in isolation or in combination with placebo or other therapies; provide comparisons with no treatment, placebo, a different mode or protocol of cryotherapy, or other physiotherapeutic interventions; and have outcome measures that included function (subjective or objective), pain, swelling, or range of motion. DATA EXTRACTION: The study population, interventions, outcomes, follow-up, and reported results of the assessed trials were extracted and tabulated.The primary outcome measures were pain, swelling, and range of motion. Only 2 groups reported adequate data for return to normal function. All eligible articles were rated for methodologic quality using the PEDro scale. The PEDro scale is a checklist that examines the believability (internal validity) and the interpretability of trial quality. The 11-item checklist yields a maximum score of 10 if all criteria are satisfied. The intraclass correlation coefficient and kappa values are similar to those reported for 3 other frequently used quality scales (Chalmers Scale, Jadad Scale, and Maastricht List). Two reviewers graded the articles, a method that has been reported to be more reliable than one evaluator. MAIN RESULTS: Specific search criteria identified 55 articles for review, of which 22 were eligible randomized, controlled clinical trials. The articles' scores on the PEDro scale were low, ranging from 1 to 5, with an average score of 3.4. Five studies provided adequate information on the subjects' baseline data, and only 3 studies concealed allocation during subject recruitment. No studies blinded their therapist's administration of therapy, and just 1 study blinded subjects. Only 1 study included an intention-to-treat analysis. The average number of subjects in the studies was 66.7; however, only 1 group undertook a power analysis. The types of injuries varied widely (eg, acute or surgical). No authors investigated subjects with muscle contusions or strains, and only 5 groups studied subjects with acute ligament sprains. Theemaining 17 groups examined patients recovering from operative procedures (anterior cruciate ligament repair, knee arthroscopy, lateral retinacular release, total knee and hip arthroplasties, and carpal tunnel release). Additionally, the mode of cryotherapy varied widely, as did the duration and frequency of cryotherapy application. The time period when cryotherapy was applied after injury ranged from immediately after injury to 1 to 3 days postinjury. Adequate information on the actual surface temperature of the cooling device was not provided in the selected studies. Most authors recorded outcome variables over short periods (1 week), with the longest reporting follow-ups of pain, swelling, and range of motion recorded at 4 weeks postinjury. Data in that study were insufficient to calculate effect size. Nine studies did not provide data of the key outcome measures, so individual study effect estimates could not be calculated. A total of 12 treatment comparisons were made. Ice submersion with simultaneous exercises was significantly more effective than heat and contrast therapy plus simultaneous exercises at reducing swelling. Ice was reported to be no different from ice and low-frequency or high-frequency electric stimulation in effect on swelling, pain, and range of motion. Ice alone seemed to be more effective than applying no form of cryotherapy after minor knee surgery in terms of pain, but no differences were reported for range of motion and girth. Continuous cryotherapy was associated with a significantly greater decrease in pain and wrist circumference after surgery than intermittent cryotherapy. Evidence was marginal that a single simultaneous treatment with ice and compression is no more effective than no cryotherapy after an ankle sprain. The authors r reported ice to be no more effective than rehabilitation only with regard to pain, swelling, and range of motion. Ice and compression seemed to be significantly more effective than ice alone in terms of decreasing pain. Additionally, ice, compression, and a placebo injection reduced pain more than a placebo injection alone. Lastly, in 8 studies, there seemed to be little difference in the effectiveness of ice and compression compared with compression alone. Only 2 of the 8 groups reported significant differences in favor of ice and compression.

CONCLUSIONS: Based on the available evidence, cryotherapy seems to be effective in decreasing pain. In comparison with other rehabilitation techniques, the efficacy of cryotherapy has been questioned. The exact effect of cryotherapy on more frequently treated acute injuries (eg, muscle strains and contusions) has not been fully elucidated. Additionally, the low methodologic quality of the available evidence is of concern. Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury.

Scand J Med Sci Sports. 1996 Aug;6(4):193-200

Cryotherapy in sports medicine. Swenson C, Swärd L, Karlsson J.

Department of Orthopaedics, Ostra University Hospital, Göteborg, Sweden.

The use of cryotherapy, i.e. the application of cold for the treatment of injury or disease, is widespread in sports medicine today. It is an established method when treating acute soft tissue injuries, but there is a discrepancy between the scientific basis for cryotherapy and clinical studies. Various methods such as ice packs, ice towels, ice massage, gel packs, refrigerant gases and inflatable splints can be used. Cold is also used to reduce the recovery time as part of the rehabilitation programme both after acute injuries and in the treatment of chronic injuries. Cryotherapy has also been shown to reduce pain effectively in the post-operative period after reconstructive surgery of the joints. Both superficial and deep temperature changes depend on the method of application, initial temperature and application time. The physiological and biological effects are due to the reduction in temperature in the various tissues, together with the neuromuscular action and relaxation of the muscles produced by the application of cold. Cold increases the pain threshold, the viscosity and the plastic deformation of the tissues but decreases the motor performance. The application of cold has also been found to decrease the inflammatory reaction in an experimental situation. Cold appears to be effective and harmless and few complications or side-effects after the use of cold therapy are reported. Prolonged application at very low temperatures should, however, be avoided as this may cause serious side-effects, such as frost-bite and nerve injuries. Practical applications, indications and contraindications are discussed

Br J Sports Med. 2006 Aug;40(8):700-5; discussion 705. Epub 2006 Apr 12.

Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols.

Bleakley CM, McDonough SM, MacAuley DC, Bjordal J.

Health and Rehabilitation Sciences Research Institute, University of Ulster, Jordanstown BT37 0QB, County Antrim, Northern Ireland, UK

Comment in: Clin J Sport Med. 2007 Jul;17(4):335.

BACKGROUND: The use of cryotherapy in the management of acute soft tissue injury is largely based on anecdotal evidence. Preliminary evidence suggests that intermittent cryotherapy applications are most effective at reducing tissue temperature to optimal therapeutic levels. However, its efficacy in treating injured human subjects is not yet known. OBJECTIVE: To compare the efficacy of an intermittent cryotherapy treatment protocol with a standard cryotherapy treatment protocol in the management of acute ankle sprains. SUBJECTS: Sportsmen (n = 44) and members of the general public (n = 45) with mild/moderate acute ankle sprains. METHODS: Subjects were randomly allocated, under strictly controlled double blind conditions, to one of two treatment groups: standard ice application (n = 46) or intermittent ice application (n = 43). The mode of cryotherapy was standardised across groups and consisted of melting iced water (0 degrees C) in a standardised pack. Function, pain, and swelling were recorded at baseline and one, two, three, four, and six weeks after injury. RESULTS: Subjects treated with the intermittent protocol had significantly (p<0.05) less ankle pain on activity than those using a standard 20 minute protocol; however, one week after ankle injury, there were no significant differences between groups in terms of function, swelling, or pain at rest.

CONCLUSION: Intermittent applications may enhance the therapeutic effect of ice in pain relief after acute soft tissue injury.

Arch Phys Med Rehabil. 2005 Jul;86(7):1411-5.

Comparison of skin surface temperature during the application of various cryotherapy modalities.

Kanlayanaphotporn R, Janwantanakul P.

Department of Physical Therapy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand. rotsalai.k@chul.ac.th

OBJECTIVE: To compare the skin surface temperature during the application of 4 cryotherapy modalities. DESIGN: A repeated-measures design. SETTING: Laboratory experiment. PARTICIPANTS: Convenience sample of 50 women (age range, 20-23 y; mean, 20.6+/-0.8 y). INTERVENTIONS: Each of the 4 cryotherapy modalities (ice pack, gel pack, frozen peas, mixture of water and alcohol) was applied randomly to the skin overlying the right quadriceps femoris muscle. MAIN OUTCOME MEASURE: Skin surface temperature recorded every minute for 20 minutes. RESULTS Throughout 20 minutes of cryotherapy application, the ice pack and mixture of water and alcohol showed significantly lower skin surface temperatures than the gel pack or frozen peas (P < .001). The mean skin surface temperature at the 20th minute of application with the ice pack, gel pack, frozen peas, and mixture of water and alcohol was 10.2 degrees +/-3.5 degrees , 13.9 degrees +/-4.1 degrees , 14.4 degrees +/-3.0 degrees , and 10.0 degrees +/-4.5 degrees C, respectively.

CONCLUSIONS: The ice pack and mixture of water and alcohol were significantly more efficient in reducing skin surface temperature than the gel pack and frozen peas.

J Strength Cond Res. 2009 Jan;23(1):44-50.

Functional performance following an ice bag application to the hamstrings.

Fischer J, Van Lunen BL, Branch JD, Pirone JL.

Department of Exercise Science, Sports Medicine Research Laboratory, Old Dominion University, Norfolk, Virginia, USA.

This study examined the immediate and short-term (20 minute) effects of 3- and 10-minute ice bag applications to the hamstrings on functional performance as measured by the cocontraction test, shuttle run, and single-leg vertical jump. Forty-two (25 women, 17 men) recreational or collegiate athletes who were free of injury in the lower extremity 6 months before testing and who did not suffer from allergy to cryotherapy were included. Time to completion was measured in seconds for the cocontraction and the shuttle run test. Single-leg vertical jump was measured on the Vertec (Sports Imports, Columbus, Ohio) in centimeters. The 10-minute ice bag application reduced immediate post-application vertical jump performance and increased immediate post and 20-minute post shuttle run time (p <or= 0.05). A decrease in cocontraction time was observed at 20 minutes post compared with preapplication during the control condition in which no ice bag was applied. Power and functional performance are affected by short-term cryotherapy application. Power and functional performance was impaired immediately and 20 minutes after 10-minute ice bag application to the hamstrings, whereas a shorter duration of ice application had no effect on these tasks.

Emerg Med J. 2008 Feb;25(2):65-8

Is ice right? Does cryotherapy improve outcome for acute soft tissue injury?

Collins NC.

Department of Emergency Medicine, University Hospital Galway, Newcastle Road, Galway, Ireland. nievoc@yahoo.co.uk

Comment in:

Emerg Med J. 2009 Jan;26(1):76.

AIMS: The use of ice or cryotherapy in the management of acute soft tissue injuries is widely accepted and widely practised. This review was conducted to examine the medical literature to investigate if there is evidence to support an improvement in clinical outcome following the use of ice or cryotherapy. METHODS: A comprehensive literature search was performed and all human and animal trials or systematic reviews pertaining to soft tissue trauma, ice or cryotherapy were assessed. The clinically relevant outcome measures were (1) a reduction in pain; (2) a reduction in swelling or oedema; (3) improved function; or (4) return to participation in normal activity. RESULTS: Six relevant trials in humans were identified, four of which lacked randomisation and blinding. There were two well conducted randomised controlled trials, one showing supportive evidence for the use of a cooling gel and the other not reaching statistical significance. Four animal studies showed that modest cooling reduced oedema but excessive or prolonged cooling is damaging. There were two systematic reviews, one of which was inconclusive and the other suggested that ice may hasten return to participation.

CONCLUSION: There is insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries.

Ann Phys Rehabil Med. 2009 Apr;52(3):246-55. Epub 2009 Feb 23.

Treatment of muscle trauma in sportspeople (from injury on the field to resumption of the sport).

Guillodo Y, Saraux A.

Service de rhumatologie, CHU de la Cavale-Blanche, Brest, France. yannick.guillodo@chu-brest.fr

OBJECTIVE: Muscle trauma mainly results from sporting activities and accounts for 10 to 55% of sports injuries. However, information on optimal muscle trauma management is scarce. The present study sought to assess the initial treatment of muscle injury in sportspeople, evaluate rehabilitation programs and observe the impact on healing. METHODS: We included consecutive patients consulting for severe muscle pain with a physician at the Questel Sports Medicine Surgery in the city of Brest (western France). The study examined the circumstances of the injury, possible antecedents and the initial treatment (with the RICE protocol). After clinical and ultrasound examinations, each patient was referred to the physiotherapist of his/her choice with an identical recovery program (muscle strengthening exercises, cycling on an exercise bike and guidance on resuming sport). The patient was subsequently interviewed by phone at two time points: four months after the injury, to ascertain the date of resumption of gentle sporting activity (e.g., jogging) or return to the pre-injury sporting level (i.e., full recovery) and to establish whether the patient and the physiotherapist had respectively complied with the prescribed treatment and 15 months after the injury, to investigate any re-injury and/or any other muscle injuries. The patients were classified into two groups: those who were able to resume full sporting activity within 40 days (minor muscle injuries: Group 1) and those who were also able to resume full sporting activity but only after more than 40 days (major muscle injuries: Group 2). We, then, compared the two groups in order to identify factors potentially related to recovery. RESULTS: Ninety-five cases were included in the study; this corresponded to 93 patients, two of whom had two different injuries each. The RICE protocol: sport was immediately discontinued in 90 cases and shortly afterwards in five cases. Ice was applied in 57 cases (60%) and compression was applied in 17 cases (17.8%). There were 34 patients (35.8%) in Group 1, with an average return to gentle sporting activity (jogging) on day 11 post-injury and full resumption of their sport on day 23. There were 61 cases (64.2%) in Group 2, with an average return to jogging on day 39 and full resumption of their sport on day 69. Compliance with the prescription: rehabilitation was performed in only 62 cases (64.5%), with no major difference between the two groups. In terms of the physiotherapist's compliance with the prescription, 40 of the 62 patients did some weight training, 29 performed cycling and 58 were given advice on the resumption of sporting activity. Resumption of sport: in both groups, the duration of incapacity did not depend on whether rehabilitation had been performed or not. The second phone interview yielded a total of 84 replies (88%): seven patients (8%) had suffered re-injury in the same muscle group (no difference between Groups 1 and 2) and 22 patients (26%) had incurred injuries in another muscle group.

CONCLUSION: The RICE protocol might give better results if compression were to be used more extensively. In terms of rehabilitation, therapeutic compliance is rather weak and physiotherapists do not fully comply with physician's prescription. However, for both minor and major injuries, rehabilitation (to the extent that it was implemented by the physiotherapists in the present study) did not lead to quicker recovery.

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