RICE: Yes or No

[Canuck Physio]

Hello,

I did post a link to one study, but no where did I state that this is the be all and end all of cryotherapies role in physiotherapy treatment. The intent of the post was to show that there is disagreement between some studies, and it is very difficult for us to measure the true or clinically meaningful effect of any given therapy. Physiotherapy treatment in general will in many cases be a maximum of 8 say, on the Pedro scale simply because for most modalities we simply can not blind the patients or the therapists to the treatment, and not to mention the influence of the Placebo, Nocebo, and Hawthorne effects!

The key issue is there are studies evaluating the use of certain conditions, and we aught to be aware of what is the most effective treatment (regardless of whether or not we know the 'true' physiological treatment effect).

I believe Cryotherapy is very useful based on personal use, but I also understand that certain forms of cryotherapy are far more effective than others. For example, I do believe that ibuprofen cryo gel's inhibit repair, just as after a bout of intense exercise the normal hypertrophy post exercise response is blunted by ingesting ibuprofen. It is important to understand and question the physiological basis of any given treatment, else we may continue to do same old without realising our err's.

Good post btw.

[Dr Damien]

I agree quite frankly. blinding is a problem only because of ethical issues mainly. In other countries where ethical issues are not that stringent trials are adequately blinded. The pedro scale is limited in content in some parts and except i am mistaking it for the modified version, it mentions nothing on sample size or power calculation.
Assessing quality of a study goes beyond just blinding,you still have other options e.g sample size , randomization etc. The study design will help one decide whether to assess it stringently or give it some leeway. You identify only RCTS somewhat in your point.
My point in response to your reply is that, first of all clinically meaningful effect, yes very difficult to assess on a personal note except you have a wealth of experience however some studies do report it. It is important that a good study gives some clinical relevance either in the discussion or statistcally not just statistical significance.

I think when it comes to cryotherapy, the basis behind the effect should be acknowledged first. If any contradictions must be raised then it should be in scrutiny of what has been claimed, what is experienced(by that I mean thorough reflection of one's own practice) which means we should at least try and be familiar with the literature before we put out ideas. if I told you the earth was flat and the UK was the world will you believe me? NO, because you know better and you know better because you have seen the world from Tv or probably have travelled to other parts of the world;well if I told that to a two year old then I would be misinforming that two year old, init?

If a lot of new physios assess this site on a regular basis hoping to get quality info then it is our duty to make sure that happens.

I would have agreed with the subject if the thought was lets try other treatment possibilities not lets try other treatment possibilities because this is not effective when clearly I know only a tiny part of the story, that is being biased.

The only way to know what is most effective is if you pit both treatments against each other in a trial but before you can do that again you need to be aware of what each treatment does or what has been claimed it does right?

and if the literature is limited in that field you would be justified for trying something new. Nothing was mentioned about types of cryotherapy modalities, nothing was mentioned about depth of cooling, nothing was mentioned about lasting effect of cooling etc yet the thought was vasodilation, the way the body heals itself. Yes the body will heal itself but cryo is not giving for symptomatic relief. Read any current paper today and the first thing you will see is it is given to prevent secondoray hypoxic injury which will occur from metabolic demand on starved tissues when the area is hot. That is the primary concern, pain reduction and swelling happen to follow suit.

the idea is to make sure cells dont die anymore.The body increases vasodilation but remember reperfusion injury occurs.these are the reasons why cryo is important.

If physiomitch had presented his case saying, "hey guys look cryo is claimed to do this, decrease metabolism to prevent hypoxic injury but after searching I could not find one study that supported the idea" then I would have been like"really?, interesting so we have been lied to!"

Physiomitch said he gets fairly good results from trying low dose cryo. It should be excellent results if it was sound. I agree that studies tend to show equivocal results most of the time, this is where the physios critiquing and appraising skills come to play.

If you treated a few minimal sprain injuries and you get excellent results all the time with any treatment, that does not mean you will get the same results if the sprain was really bad.

To finish up, You say we need to be aware of what the most effective treatment is and that there are studies out there. Couldnt agree with you anymore on that, but how do you know which treatment is effective or which study is meaningful when you are not informed ?

I do not believe cryotherapy is the most effective acute soft injury management out there but I would not castigate any treatment until I am scientifically aware of everything about that treatment. That is how a true scientist thinks. I just read in the papers today, British medical experts and scientists have travelled outside the UK to do what?, investigate the secrets behind the health"INESS" of rural countries and remote tribes who do not even have a healthcare system.

I'm sorry if I misread your train of thought.

[Canuck Physio]

I understand what you are trying to say, although I don't realise what we are discussing now

It is probably important to keep this in context, I am not trying to claim the earth is flat, and I don't do anything of the sort when providing treatment to a patient. I feel it is important to inform the patient, and thus it is important to use a variety of literature (sys reviews, RCTs, etc) which are ethical, have stringent quality of methodology, and are peer reviewed.

If we take for example Chiropractic in North America, which initially began as an 'Art' of spinal manipulation and a treatment modality for 'subluxations'. And many unscrupulous individuals consistently tell patients that they 'need' or 'require' x amount of sessions. Other examples include certain electrotherapies that are touted to work, but lack sufficient evidence.

By providing the above example I am not trying to antagonize either, rather they appear to have their use in certain situations. This is key, and it certainly is the case in many physiotherapy modalities.

Another example includes stretching, for many many years it was considered the norm to stretch (static) before a workout (lets say weight training session) to avoid injury. But significant and mounting evidence just shows that this is not the case, and in fact static stretching before weight lifting attempts decreases subsequent force output. Yet, how often does static stretching take the place of an appropriate warm up before weight training?

In regards to this subject, I agree with cryotherapy and I am not claiming that it has no use in RICE.

"Couldnt agree with you anymore on that, but how do you know which treatment is effective or which study is meaningful when you are not informed ?"

My personal opinion is that the mind-body power effect is quite powerful, and results of many studies (placebo, nocebo, hawthorne effect) can certainly sway the quality of a study. For this reason there is debate about this very topic, what is the role of acupuncture, what is the role of electrotherapies, do they work, if they do what specifically for? I recently reviewed (personally) all the literature surrounding constraint induced movement therapy CIMT, and I can not say for sure that CIMT is any more useful than Neuro Development Training (NDT) at enhancing function in Post-Stroke patients, but I am sure that Taub and his followers are quite adamant that it is the revolutionary therapy that will change the world.

So basically, I am not 'castigat[ing]' cryotherapy in any way, I think that we should consider the evidence to inform clinical decision making.

Personally, I have seen great success with Cryotherapy. But sometimes patients respond better to heat therapy than cryo.

"That is how a true scientist thinks. I just read in the papers today, British medical experts and scientists have travelled outside the UK to do what?, investigate the secrets behind the health"INESS" of rural countries and remote tribes who do not even have a healthcare system.

I'm sorry if I misread your train of thought."

I got another good one for you:

Why is it that US which spends the most money towards medicare and pharmacology, has the highest rates of cancer, diabetes, hypertension, and disease in the world? On the other hand, Cuba which spends some of the least towards a virtually negligible medicare system, has the lowest rates of cancer, diabetes, hypertension, and disease in the world?
I think this is where Physiotherapy will play one of the largest roles in the future, but that is up to debate (that is prevention).

And I would say that this is an interesting discussion, it is one of the first I have seen on this forum in a while.