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New Clinical Perspectives in Edema Management
Michael G. Dolan, MA, ATC, CSCSPeter Canisius Distinguished Teaching ProfessorDirector, Center for Health and Sports Medicine
2005 EATA Meeting and Clinical Symposium
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Early Treatment Speeds Recovery
Does it?If so, which treatments work and which don’tSome “therapeutic“ interventions probably have no clinical benefitStatistical significance vs. clinical meaningfulnessHow can we optimized our clinical treatmentsBridging the gap between basic science and clinical practice
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Ankle Injuries
Account for 25% of all missed practices and games in high school and college athleticsEdema Management is a key component in the rehabilitation process
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PRICE
STIM NSAIDS
CONTRAST
BATHS
Focal Compression
Intermittent
CompressionTENS
Other Stuff
Massage
ACUTE TRAUMA MANAGEMENT
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The most common clinical practice in sports medicine
“Put some ice on it”Does ice reduce swelling after an ankle sprain?
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Cryotherapy
Reduces blood flowReduce metabolic activityKnight suggested the Secondary Injury ModelDoes the reduction in cell metabolism have any meaningful clinical affect on return to play?Rippe and Grega suggested that cold therapy decreases permeability of post capillary venules Acta Physiol Scand 1978, 103(3) 252-62
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Hocutt et al.
Am J Sports Med 1982, 10(5) 316-9.
Compared Heat and cold on acute ankle sprains
No Controls
Did cold make it better or did heat make it worse?????
Concluded that cold worked better than heat
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Cote, Prentice, Hooker & Shields
Phys Ther 1988, 68(7) 1072-6.
Cold vs. Heat vs. Contrast Bath
Ankle sprains that were subacute
Randomized into 3 Treatment Groups
Measurement error was greater than treatment effect
No Control Group
All three treatments caused an increase in swelling
Cold was the least
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Sloan et al. Arch Emerg Med 1989, 6(1) 1-6.
Acute ankle sprains from an emergency room
Applied a single ice treatment for 30 minutes
Evaluated them 7 days later
Not surprisingly, the authorsfound no treatment effect
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Human Studies
No compelling evidence that cryotherapy controls edema
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Animal Studies
Allow for greater control of variablessmaller samplesInternal Validity is highcan have control groupsSimilar physiologyCommonly used in all medical fields
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Summary of Animal StudiesMcMaster & Liddle, 30°C was most effective, however, control limbs had the least swelling
Farry et al. Ice increased swelling but less histology evidence of inflammation
Cryotherapy increases swelling after injury!!
Jedinsky et al. No treatment effect from ice
limbs swelled after ice was removed
Matsen et al. Used water from 5-25°CTreated limbs were more swollen
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Literature Review
No scientific evidence that Cryotherapy controls edema formation after acute traumaMost of the data suggests that ice increases swelling
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Effects of cold water immersion on edema formation following blunt trauma to hind limbs of
rats
Michael G. Dolan, MA, ATC, CSCSRichard M. Thornton, Ph.D.
Dale Fish, Ph.D, PTFrank C. Mendel, Ph.D
JAT 1997, 32(3) 233-37.
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Results
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Cryotherapy
Cryotherapy is effective in curbing edemaTreatment effect in spite of dependent positioningCool Water 55° DegreesDoes it positively affect functional outcomes or return to play?
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Systematic Review of Cryotherapy on Return to Play
83 relevant clinical trials79 were excluded because they did not include return to play as an outcome4 reviewed studies
2 had a positive RX effect
1 had a positive effect but attributed it to compression
1 showed no difference
All had PEDro Scores of 3 or 4 (1-10)
Hubbard et al JAT 39(1) 88-94
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Compression
Mechanically control swelling by increasing the hydrostatic pressure against the capillary wallHow much compression is enough?What mode of compression?
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Uniform Compression
Ace bandageCompression sleeve materialEqual pressure around the limbEasy to apply and inexpensive
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Focal Compression
Take advantage of bodies concavities and convexities
Popular but unproven
Continual application is probably one reason for its effectiveness
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Focal Compression
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What type of compression works best?
Compared uniform, focal, and focal+cold compression on 34 subjectsNo difference between groups p<.05Calculated effect size would suggest a small effect or little clinical significance.
Wilkerson & Horn-Kingery, JOSPT, 1993(17) 240-246
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Comparison of 3 Methods of External Support for Management of Acute Lateral Ankle SprainsGuskiewicz et. al JAT 34(1) 5-10
Acute Ankle Sprains
Aircast Omni MultiphaseElastic Wrap &
Horseshoe
None of the three were superior in increasing range of motionRestoring function, or relieving symptoms
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Intermittent Compression
Static or rhythmic air contraction of sleeve
Affect the pressure gradient of the tissue
Tsang et al. JAT 2003, 38(4) 320-24
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Elevation
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Elevation
Probably works but treatment effect is very shortElevation and intermittent compression effect lasts less than 5 minutesStatistical effectiveness vs. Clinical effectiveness
Tsang et al. JAT 2003, 38(4) 320-24
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Summary– So Far
Limited evidence that ice, compression, elevation at typically applied by certified athletic trainers has any meaningful treatment effect Time to try something new!
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Standard of Care
Rest
Ice
PRICEProtection
Compression
Elevation
OTHER RX
NSAIDS
Stim
Contrast Baths
Joint Mobilizations
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High Voltage Electrical Stimulation
Long touted by clinicians as an effective tool in managing pain and edemaLike ICE, limited evidence that it hastens recovery Work from our lab has established that some forms of electrical stimulation curb edema formation using animal models in spite of dependent positioning
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Charactertics of High Voltage Stimulation
5 8
High Voltage
Low average current
Monophasic-Twin Peak
Duty Cycle less than 1-2%
Voltage
75
Time (ms)
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Effects of cool water immersions and high voltage electrical
stimulation on edema formation following blunt trauma to the hind
limbs of rats
Michael G. Dolan, MA, ATC, CSCSAnna M. Mychaskiw ATC
Frank C. Mendel, PhD
JAT 2003, 38(3) 225-30 Sponsored by NYSATA
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Cryotherapy CHVPC
Decreases Metabolic Activity Decrease in Capillary Permeability
Greater Treatment Effect duringAcute Edema Formation
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3 Experimental Groups
Cool Water Immersion at 12.8C (CWI)Cathodal high voltage electrical stimulation at 120 pps and 90% motor threshold (CHVPC)CWI + CHVPC
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Results
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
1.1
Pre-Trauma
0 30 60 90 120 150 180 210 240
Time (min)
Chang
e in Lim
b Volu
me (m
L/kg)
Treated Limb
Untreated Limb
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ICE + STIM had no added effect
Comparison of Treatment
-0.2
0
0.2
0.4
0.6
0.8
1
1.2
Pre-Trauma
0 30 60 90 120 150 180 210 240
Time (min)
Chan
ge in
Volum
e (ml
/kg)
CWI
CHVPC
CWI+CHVPC
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Electrical Stimulation
Effective in curbing limb volumes in spite of dependent positioningAs effective as Cryotherapy?How does it work?
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Physiology of Microvessel Permeability
Normally, walls of microvessels are freely permeable to water and dissolved ions and partially permeable to large plasma proteinsHistamine dramatically increases permeability so even macromolecules can escapePermeability increases due to gaps between normally abutted endothelial cells
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Normal State of Capillary Physiology
Capillary Walls
Capillary Walls
Endothelial Cells
Plasma ProteinsTissue Cell
Tissue Cell
Lymph Gland
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Inflammatory Reaction
Capillary Walls
Capillary Walls
Endothelial Cells
Tissue Cell Tissue
Cell
Lymph Gland
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Proposed Mechanism of Action
Capillary Walls
Capillary Walls
Smooth Muscle Actin and Myosin
Endothelial Cells
Tissue Cell Tissue
Cell
Lymph Gland
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RXRE
ST
RX REST
“Staircase Effect”
Control Limbs
Continuous RX
Limb
Volumes
30 60Trauma 0 90 120
Time
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Effects of cool water immersion and high voltage electrical
stimulation on edema formation for three continuous hours
Michael G. Dolan, ATC, CSCSAnna Mychaskiw, ATC
Carl Mattacola, PhD ATCFrank C. Mendel, PhD
JAT 2003, 38(4) 225-229 Supported by a NYSATA Grant
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Effects of Continuous Treatment
0
0.2
0.4
0.6
0.8
1
1.2
Pre-T 0 30 60 90 120 150 180 210 240
Minutes
Cha
nge
in L
imb
Volu
me(
mL/
Kg)
UntreatedTreated
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Application of HVPC via electrode socks
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What Doesn’t Curb Edema
Low Volt Stimulation“pumping action”Short treatment times probably have no long-term clinical effect
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Polarity Matters!!!
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Anodal High Voltage Pulsed Current
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PRICE
STIM NSAIDS
CONTRAST
BATHS
Focal Compression
Intermittent
CompressionTENS
Other Stuff
Massage
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RXRE
ST
RX REST
“Staircase Effect”
Control Limbs
Continuous RX What other types of
RX can be used for
extended times?
Limb
Volumes
30 60Trauma 0 90 120
Time
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Effects of Ibuprofen & Electrical Stimulation on Edema Formation
following Blunt Trauma to the Hind Limbs of Rats
Michael G. Dolan, MA, ATC, CSCSPaul Graves, ATS
Chika Nakazawa, ATSTheresa Delano, ATC
Alan Hutson, PhD Frank C. Mendel, PhD
2004 EATA Funded Research Award
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Ibuprofen
Nonsteroidal anti-inflammatory Drug (NSAID)Treatment of OA and RA Available by prescription or OTCEffectiveness of Ibuprofen on acute swelling has not been investigatedSeldom used as a first aid treatment
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Greater Treatment Effect duringAcute Edema Formation
+Inhibits ProstaglandinCascade
Decrease in Capillary Permeability
Ibuprofen CHVPC
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Methods
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Subjects and Methods
21 Zucker Lean ratsAnesthetized by IP injection of Sodium pentobarbital(60mg/kg of body weight)Supplemented as needed during the 4 hour experiment
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Measurement System
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Measurement System
Measurement Tank
Syringe
Motor Control
Tubing
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Limb Volume Measurement
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Calculating Limb Volume
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Ibuprofen
Equivalent of an 800 mgGavage
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CHVPC
Anode Cathode
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CHVPC
120 pps at 90% visible motor contraction
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Trauma
Trauma induced by dropping a steel rod(85 grams) through a plexi-glass tube from a height of 30 cm.Causes edema and not frank bleeding
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Treated vs. Untreated Limb
0
0.2
0.4
0.6
0.8
1
1.2
Pre-T 0 30 60 90 120 150 180 210 240
Minutes
Cha
nge
in L
imb
Volu
me(
mL/
Kg)
UntreatedTreated
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No Treatment Was Superior
0
0.1
0.2
0.3
0.4
0.5
0.6
Pre-T 0 30 60 90 120 150 180 210 240
Minutes
Cha
nge
in L
imb
Volu
me
(mL/
kg)
Ibuprofen
CHVPC
Ibuprofen + CHVPC
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Ibuprofen
Effective in curbing acute edema formation when ingested immediately after traumaMay be as effective as traditional therapiesIncreased effectiveness because of mode of delivery & improved complianceBroad spectrum of physiological effects
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IBUPROFEN + CHVPC
+ = Greater RX Effect
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Price($) and Compliance are the next major considerations
Can these results be replicated in humans?
=Cool Water Immersions
High Voltage
Pulsed CurrentIbuprofen (NSAIDS)=
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An Animal Model to Determine the Effectiveness of Acute Care on
Restoration of Functionfollowing Contusions and Sprains
Michael G. Dolan MA, ATCFrank C. Mendel, PhD
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Measurement of Edema
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Measurement of Function
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Effects of RICE and NSAIDs on pain, swelling, and time to recovery following
knee surgeryA Randomized Clinical Trial
John Leddy, MDFrank C. Mendel, PhD
Michael G. Dolan, MA, ATCDale Fish, PhD, PT
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Surgical Knee Patients
OUTCOMERICE
PAIN
+RICE + NSAIDS
ExerciseSWELLINGNSAIDS
Alone
Tylenol FUNCTION
Placebo
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The Big Question
What effect do our “TREATMENTS” have on return to play??
PAIN SWELLING
REDUCE AMOUNT OF TIME LOSTBECAUSE OF INJURY
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Effects of electrical stimulation on pain, edema and return to play
following ankle sprains in college and professional athletes
A Multi-Center Randomized Clinical Trial
Frank C. Mendel PhDMichael G. Dolan, MA, ATC
John Marzo, MDDale Fish, PhD, PT
Gregory Wilding, PhD
Funded by a grant from The National Football League
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16 Colleges and professional teams will serve as clinical sites
35 Certified Athletic Trainers will serve as data collectors
132 Grade I & II Ankle Sprains will be randomized into Treatmentand Control Groups
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Ankle Sprains & HVPC
RX GROUPElectrode Sock that delivers HVPC on a continual basis
Treat for 3 days with current on all times except when bathing or receiving RX
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Ankle Sprains & HVPCCONTROL GROUPElectrode Sock and unit that
delivers HVPC
Stimulators have been modified so that they turn on
but then shut off after 5 minutes
Look and Feel of Live Stimulators
Credible Placebo
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Core Clinical Concepts
Cool Water
Compression
CHVPC
C3
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Clinical Concepts
Whatever you do– do it fast! Treat the injury continuouslyCryotherapy for at least 30 minutesConsider extended RX timesContinuous focal compressionContinuous CHVPC while inflammation is present
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Clinical Concepts
NSAIDs as a first aid tool? Choice of Physician Reapply ice every 1.5 hours for 30-45 minutes or significant movement event Joint Mobilizations for pain and movement
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Clinical Concepts
Continue to apply C3 while acute edema is forming and continue until athlete is FWB, and 75% functionalBased upon the severity of the injury, initiate movement, propriocepetive exercises and closed chain activity ASAP
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Core Clinical Concepts
Cool Water
Compression
CHVPC
C3
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Graduate and Undergraduate Students
Julie Gandolph, ATC
Kristy Grossman, ATC
Joe Mills, ATC
Chika Nakazawa, ATC
Theresa Delano, ATC
Paul Graves, ATS
Kate Sampson, ATS
Danielle Cantanese, ATS
Anna Myschaskiw, ATC
Val Ciotti, MS, ATC
Karen Harrington, ATC
Nicole Kosich, ATC
Paul Marvar, PhD, ATC
Brian Ragan, PhD, ATC
Julie Teprovich, MS, ATC
Jeff Habicht, MS, ATC
Anne Bauer, MS, ATC
Tim Bellasri, MS, ATC
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New Clinical Perspectives in Edema Management
Michael G. Dolan, MA, ATC, CSCSPeter Canisius Distinguished Teaching ProfessorDirector, Center for Health and Sports Medicine