Submitted to the Faculty of Health at the Durban University of Technology in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Department of Chiropractic, Durban University of Technology, Durban, South Africa, 2015. / Background: Cryotherapy is often the first option in treating acute conditions and can be applied in various forms including ice packs and cooling gels. Cooling gels are easy to use and readily available making them popular with consumers. They can also contain additional ingredients which can assist with inflammation, making them ideal for musculoskeletal disorders. A cooling gel containing menthol and anti-inflammatory herbs is available in pharmacies nationwide in South Africa, but has not been clinically investigated. This gel is often used in the treatment of acute injuries such as low back pain but its effectiveness in treating this condition has not yet been verified. Objectives: To determine the effectiveness of a menthol cooling gel combined with anti-inflammatory herbs compared to a menthol gel and a placebo gel in the treatment of acute non-specific low back pain. Method: A double-blinded placebo controlled clinical trial (n = 60) was conducted. Each participant was randomly allocated into one of three treatment groups consisting of a minimum of 20 participants between the ages of 18 and 40 who met the study criteria. Informed consent was obtained from the participants prior to their participation in the study. At the initial consultation baseline measurements (pain rating, disability and pressure pain threshold) were taken and the respective treatments (menthol with anti-inflammatory herb, menthol or placebo gel) were administered. Participants were instructed on how to apply the gel at home and were requested to apply it three times a day for one week. Statistical analysis was performed using repeated measures ANOVA for inter- and intra-group analysis with one way ANOVA and chi square tests being used to compare baseline values. A p-value < 0.05 was considered to be statistically significant. The study received ethical clearance from the Durban University of Technology Institutional Research Ethics Committee (REC 81/13). Results: No significant differences were observed between the groups at baseline assessment, indicating that the groups were comparable. Participants were instructed on how to apply the gel at home and were requested to apply it three times a day for one week. Follow up appointments for data collection was scheduled at days three or four and six. No statistically significant differences were observed between the three groups over time for pain (p = 0.95), disability (p = 0.903) or pressure-pain threshold (p = 0.824), with all groups showing improvement. All three groups showed clinically significant changes in pain from moderate to mild over the duration of the study but no clinically significant changes were noted in terms of pressure-pain threshold and disability. Conclusion: The results indicate that irrespective of whether or not the gel contains active ingredients there was an improvement in acute low back pain. Further research needs to be conducted to determine if tissue depth and the concentration of the active ingredients such as menthol are factors affecting the efficacy of this gel.

Introduction: Knee osteoarthritis is one of the common causes leading to musculoskeletal disability of the elderly around the world. Total knee replacement (TKR) is an effective and common treatment for end stage knee arthritis. Most papers suggest that early rehabilitation could improve postoperative knee function. However, postoperative pain and local swelling are the complications that diminish range of motion (ROM) and inhibit patients’ recovery. A comprehensive review of the literature reveals that cryotherapy is an effective and safe method to overcome these complications. In this paper, a guideline of using cryotherapy in reducing postoperative pain and knee swelling so as to improve the ROM of patients and promote recovery after TKR has been developed. Objectives: The objectives of this translational research are: (1) to look for relevant papers that related to cryotherapy in reducing postoperative pain and knee swelling so as to improve the ROM of patients after TKR; (2) to gather and criticize the data obtained; (3) to develop a guideline of using cryotherapy in reducing pain, knee swelling and improving ROM of patients after TKR based on the evidence from the reviewed literature; (4) to assess the implementation potential of the newly developed guidelines; and (5) to establish the implementation and evaluation plans for the new innovation. Methods: An empirical literature search published from 2001 to 2011 by several searching engines regarding cryotherapy in reducing postoperative pain and knee swelling with the aim to improve the ROM of patients after TKR has been conducted. After that, the qualities of relevant studies were retrieved and criticized by using the appraisal checklist of the SIGN (2004). The derived evidences were then be summarized and synthesized. An evidence-based guideline was established with reference to the evidence from the reviewed literatures and the results of the quality assessment. Recommendations are graded by SIGN (2004). The implementation potential including transferability, feasibility and cost-benefit ratio of the innovation were assessed as well. Lastly, implementation and evaluation plans have been developed to assess and appraise the effectiveness of the new guideline. Results: Finally, seven studies were chosen as final references after methodological quality assessment. Four main types of comparison were made from these seven reviews including: (1) continuous compressive cryotherapy vs. compressive crepe bandage; (2) comparison in different temperature of cryotherapy; (3) outcome measures; and (4) complications in cryotherapy. After the summary, six main categories of recommendations were synthesized: (1) continuous compression cryotherapy; (2) effective temperature; (3) potential complications; (4) regular assessment; (5) duration; and (6) intermitted ice pack regimen. Based on these syntheses and recommendations, a guideline of using cryotherapy for patients after having TKR was developed. Conclusion: With the implementation of the newly developed evidence-based cryotherapy guidelines for patients after having TKR in local clinical settings, the improvement in the ROM of the knee joint will be anticipated as a result of the reduction in postoperative pain and knee swelling. / published_or_final_version / Nursing Studies / Master / Master of Nursing

Background: Cryotherapy is commonly used during physiotherapeutic rehabilitation of patients following total knee replacement (TKR). Evidence for treatment effectiveness within the current literature is contradictory and there are no clinical guidelines to inform cryotherapy treatment within this particular patient group. This study surveys current cryotherapy treatment efficacy in the acute post-operative management of TKR patients. Methods: In total 263 senior physiotherapists completed and returned a postal questionnaire, which, using open and closed questions investigated the use of cryotherapy following TKR. Survey results were used to inform a pragmatic randomized clinical trial (RCT) involving 133 consecutive TKR patients. The RCT investigated cryotherapy treatment efficacy in the acute post-operative management of TKR patients. Patients were randomized into three groups; no cryotherapy (NC), delayed cryotherapy (DC) and immediate cryotherapy (IC). The primary outcome measure was post-operative pain with knee swelling, active range of motion (AROM), function and levels of physiotherapy input assessed as secondary outcome measures. Observations were taken pre-operatively and at 3, 7 and 42 days post-operatively. Results: The survey reported that 33% of respondents used some form of cryotherapy routinely following TKR surgery. The two main methods of cryotherapy application were Cryocuff (59%) and crushed ice (30%). Treatments were most frequently applied between 24 hrs and 48 hrs post-surgery for 20 minutes, twice a day. Chi square analysis indicated significant differences (p<0.01) in between NHS and private sites relating to a lack of cryotherapy resources and treatment time for cryotherapy in the NHS. A lack of proven efficacy was the most cited reason for not applying cryotherapy treatment, and swelling the most common treatment indicator. There was particular uncertainty regarding the cleaning and sterilization of the Cryocuff device. The RCT indicated that patients in IC group had significantly less post-operative pain than the NC and DC groups at 3 days. Mean difference (p <0.05, 95% CI) in post-operative analogue scores (VAS, scale 0-10) was -1.6 (p <0.01, CI -2.49- to -0.707) for IC and NC; and -0.922 (p= 0.044, CI -0.183 to -0.009) for IC and DC groups. At 7 and 42 days there were significant reductions in VAS scores for both cryotherapy groups compared to the NC group. There was significant improvement in knee swelling, AROM, ability to transfer and need for additional physiotherapy in both cryotherapy treatment groups although no significant reduction in opiate requirement was found. Conclusions: In current clinical practice there was little consensus regarding treatment indicators, method of application and management of cryotherapy following TKR. However, in a RCT the use of cryotherapy combined with compression, as compared to a no cryotherapy control, led to significant reductions in patient reported pain, less post-operative swelling, greater recovery of AROM, faster return of function and less reliance on OPD physiotherapy treatment. It is concluded that cryotherapy combined with compression has an important role to play in the acute rehabilitation of TKR and should be considered as part of routine management.

The purpose of this study was to measure flexibility at the hip joint under four techniques of stretching, passive stretch-concentric contraction-passive stretch (PCP), passive stretch-three seconds isometric contraction of hip extensorsconcentric contraction of hip flexors-passive stretch (3-PIeCP) and passive stretch-three seconds isometric contraction of hip flexors-concentric contraction of hip flexorspassive stretch (3-PIfCP) based on proprioceptive neuromuscular facilitation (PNF) and passive static stretch (P). Further, this study was designed to ascertain the effect of cold application (ice) in joint range of motion of the hip extensors measured with the Leighton Flexometer.

Submitted in partial fulfillment of the requirements for Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2017. / Background: Ankle sprains are a frequently occurring injury sustained by sports individuals accounting for approximately 20% to 40% of all sports injuries (DiStefano et al. 2008; LeBrun and Krause, 2005). Ankle sprains are mainly caused by excessive inversion (Takao et al., 2005; Andersen et al., 2004), when the foot is twisted inwards and lands at a high velocity damaging the lateral capsule-ligamentous complex (Beynnon et al., 2005). According to Naqvi, Cunningham and Lynch (2012) untreated or inappropriately managed ankle sprains can lead to a cascade of negative alteration to both the joint structures and the individual’s lifestyle. According to Hale, Hertel and Olmsted-Kramer (2007) 30% of ankle sprains result in chronic ankle instability (CAI) and 78% of the CAI cases develop into post-traumatic ankle osteoarthritis. This poses a negative impact on an individual’s athletic performance. Ankle sprains can be managed conservatively with the utilization of the PRICE protocol during the acute stage, cross friction massage or instrument assisted soft tissue mobilization techniques (for example Graston®, FAKTR© Concept) for both acute and subacute ankle sprains (Bleakley, 2010). Aim: The purpose of this study was to determine the effectiveness of a myofascial treatment protocol (FAKTR© Concept) combined with cryotherapy compared to cryotherapy and sham laser in the treatment of sub-acute and acute ankle inversion sprains. Objectives: 1. To determine the effectiveness of a myofascial treatment protocol combined with cryotherapy in terms of subjective (numerical pain rating scale [NRS] and foot function index [FFI]) and objective (oedema measurements [EDM], digital inclinometer readings [DIR], algometer readings [AR] and stork balance stand test score [STR]) measurements in the treatment of acute and sub-acute ankle sprains. 2. To determine the effectiveness of sham laser combined with cryotherapy in terms of subjective (NRS and FFI) and objective (EDM, DIR, AR and STR) measurements in the treatment of acute and sub-acute ankle sprains. 3. To compare the relative improvement between the two groups in terms of subjective (NRS and FFI) and objective measurement (EDM, DIR, AR and STR). Study design: This was a quantitative randomised controlled clinical trial. Methods: Forty participants with sub-acute or acute ankle sprains of not more than three weeks were recruited into the study. All participants had a full case history, physical, and foot and ankle regional examination to assess for their eligibility for entry into the study in terms of inclusion and exclusion criteria. These participants were randomly allocated using the hat method into one of two study groups, Group A (treatment group) or Group B. Participants in Group A received a myofascial treatment protocol (FAKTR© Concept) combined with cryotherapy and Group B received cryotherapy and sham laser. These participants had four treatments in two weeks where the appropriate treatment was administered. Pre-treatment subjective (NRS and FFI) and objective (EDM, DIR, AR and STR) measurements were taken at each consultation. This data was analysed using SPSS software version 24.0. Results: The General Linear Model for repeated measures was used for the intra- group and inter-group analysis of the data. Intra-group analysis of the FAKTR© treatment group showed that the group had statistically significant improvements in terms of the subjective and objective measurements of the study with the p-value < 0.05 between all treatment periods. Intra-group analysis of the control group showed no statistically significant improvements in terms of subjective and objective measurements of the study. Inter-group analysis showed no statistically significant difference in terms of the DIR and EDM. The NRS, AR, STR and FFI readings showed statistically significant differences between the two groups with a p-value of < 0.05 mainly on the last two consultations. Conclusion: This study concluded that the myofascial treatment protocol (FAKTR© Concept) combined with cryotherapy was more effective than cryotherapy and sham laser in the treatment of sub-acute and acute inversion ankle sprains. The FAKTR© Concept treatment group appeared to show statistically significant improvements compared to the control group.

Thesis (MSc)--University of Stellenbosch, 2005. / ENGLISH ABSTRACT: Cryotherapy is one of the popular treatments used to alleviate muscle soreness, especially in the competitive sports arena. However, the therapeutic use of cryotherapy is unsubstantiated because of a lack of proper investigations in the literature, especially a hypothesised effect on muscle recovery. Thus, our aims were to characterise satellite cell (SC) activity in human subjects with delayed onset muscle soreness (DOMS) and to shed light on the effect of cryotherapy on SC activity. DOMS was induced in six male subjects (24 ± 3 years) by completion of a downhill-run (DHR) protocol (5 x 8 min bouts, 2 min rest between bouts) at 70 or 80% of their individual peak treadmill speed. Ice application was applied to only one leg per subject for 3 days: 30 min every 2 hours, 5 times per day. In total 5 muscle biopsies were obtained from each subject: 1 baseline and 4 post-DHR. Post-DHR biopsies: 1 from each leg on day 1 and 7 (1st group, n=3) and 1 from each leg on day 2 and 9 (2nd group, n=3). DOMS was successfully induced as indicated by significant increases in muscle soreness at days 1 and 2 post-DHR (P < 0.01), and creatine kinase activity at day 1 post-DHR (P < 0.01). No difference in muscle soreness was found between treated and untreated legs. SC quiescence and activation were characterised by their expression of the cell surface markers CD34 and CD56 respectively. No significant change in quiescent SC was observed in the untreated or treated legs over time. However, at day 1 post-DHR the number of quiescent SC was significantly lower in the untreated compared with the treated leg (P < 0.05). There was a significant increase in activated SC numbers at day 2 post-DHR in the untreated leg, which was sustained up to day 9 post-DHR (P < 0.01). However, no such increase was found in biopsies taken on days 1 and 7. Also, no change was found in the treated leg, however a significant difference between the number of activated SC in untreated and treated legs on days 2 and 9 post-DHR (P < 0.01) was seen. No significant effect of DOMS or ice treatment was observed for the expression of the myogenic regulatory factors, MyoD and myogenin. C2C12 cell cultures induced to differentiate, however, did stain using these antibodies. This is the first study to report an effect of cryotherapy at the tissue level. In conclusion, this study highlights many unanswered questions on the SC response to DOMS at tissue level, and lays a good foundation for future studies. / AFRIKAANSE OPSOMMING: Kreoterapie is een van die gewilde behandelings wat gebruik word om spierseerheid te verlig, veral in die kompeterende sport arena, maar die gebruik van kreoterapie is onbevestig as gevolg van ‘n gebrek aan voldoende ondersoeke in die literatuur, veral ‘n hipotese oor die effek op spier-herstel. Ons doelstellings was dus om satellietsel (SC) aktiwiteit te ondersoek in mens proefpersone met vertraagde aanvang spierseerheid (DOMS) en ook om lig te werp op die effek van kreoterapie op SC aktiwiteit. DOMS was in ses mans proefpersone (24 ± 3 jare) geїnduseer deur voltooїng van ‘n afdraend-hardloop (DHR) protokol (5 x 8 min rondtes, 2 min rus tussen rondtes) teen 70 of 80% van elkeen se individuele maksimum trapmeul-spoed. Ys was vir 3 dae op net een been per proefpersoon aangewend: 30 min elke 2 ure, 5 keer per dag. 5 spierbiopsies in totaal was van elke proefpersoon verkry: 1 basislyn en 4 post-DHR. Post-DHR biopsies: 1 van elke been op dae 1 en 7 (1ste groep, n=3) en 1 van elke been op dae 2 en 9 (2de groep, n=3). DOMS was suksesvol geїnduseer soos aangedui deur die betekenisvolle verhogings in spierseerheid op dae 1 en 2 post-HR (P < 0.01) en kreatien kinase aktiwiteit op dag 1 post-DHR (P < 0.01). Geen verskil in spierseerheid is gevind tussen die onbehandelde en behandelde bene nie. SC dormansie en aktivering was gekarakteriseer deur die onderskeidelike uitdrukking van die sel oppervlak merkers CD34 en CD56. Geen betekenisvolle verandering is in SC dormansie in die onbehandelde en behandelde bene waargeneem nie, maar op dag 1 post-DHR was die getal dormante SC betekenisvol laer in die onbehandelde been as in die behandelde been (P < 0.05). Daar was ‘n betekenisvolle verhoging in die getalle geaktiveerde SC op dag 2 post-DHR in die onbehandelde been wat volgehou was tot op dag 9 post-DHR (P < 0.01), maar so ‘n verhoging was nie in biopsies wat op dae 1 en 7 geneem is gevind nie. Daar is ook geen verandering in die behandelde been gevind nie, maar ‘n betekenisvolle verskil in die getal geaktiveerde SC is tussen die onbehandelde en behandelde bene op dae 2 en 9 post-DHR gevind(P < 0.01). Geen betekenisvolle effek van DOMS en ys-aanwending vir die uitdrukking van die miogeniese (myogenic) regulatoriese faktore, MyoD en myogenin, is waargeneem nie. C2C12 sel kulture wat geїnduseer is om te differensieer het wel gekleur vir hierdie antiliggame. Dit is die eerste studie wat ‘n effek van kreoterapie op weefselvlak rapporteer. Ten slotte, hierdie studie beklemtoon baie onbeantwoorde vrae oor die SC respons op DOMS op weefselvlak en dit lê ‘n goeie grondslag neer vir toekomstige studies.

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2015. / Background: When a soft tissue injury occurs the blood vessels and surrounding tissue are damaged leading to haemorrhaging and inflammation. Cryotherapy (cold therapy) is generally acknowledged as the preferable treatment by manual therapists during this immediate post-traumatic period of an injury. Cryotherapy has been shown to result in vasoconstriction decreasing the rate of blood flow which has a favourable effect on inflammation and pain. The commercially available cooling cuff is a relatively new cryotherapy modality offering a mechanism of cooling that does not require freezing and is easy to use. The polymer granules within the cooling cuff are activated by emersion in water therefore freezing is not required making the cooling cuff readily available compared to more traditional forms of cryotherapy. Aim: The aim of this study was to determine the effect of a moist ice pack and a commercially available cooling cuff radial artery blood flow (cm.s-1) and radial artery lumen diameter (mm) after 15 minutes of application. Method: This study was a pre-test post-test design utilising 43 asymptomatic participants that were randomly allocated to one of two groups. Each group either received a standard moist ice pack or a commercially available cooling cuff, placed on the ventral surface of the participants forearm, over the radial artery, for a duration of 15 minutes. Measurements were taken with a Doppler ultrasound to determine radial artery blood flow and lumen diameter, prior to the intervention and 15 minutes after the cryotherapy application. Data analysis was performed using IBM SPSS VERSION 20 (IBM Corp. Released 2010.IBM SPSS Statistics for Windows, Version 19.0. Armonk, New York: IBM Corp.). Statistical significance was set at a p< 0.05 level. Intra-group and inter-group comparisons were measured using repeated measures ANOVA testing. Results: Both the moist ice pack and commercially available cooling cuff resulted in a significant decrease in radial artery blood flow (p< 0.001) after 15 minutes of application with no significant changes being observed in radial artery diameter Conclusions: The commercially available cooling cuff resulted in a similar effect on radial artery blood flow and lumen diameter as moist ice, indicating that the commercially available cooling cuff may be utilised in the acute phase of an injury to alter blood flow. / M

M.Tech. / Purpose: This randomised, controlled, comparative pilot study was undertaken in order to investigate the effectiveness of the chiropractic manipulation alone, the chiropractic manipulation followed by heat therapy or the chiropractic manipulation followed by cryotherapy in the treatment of cervical facet syndrome. It was hypothesised that all three treatment protocols would be effective, but that applying chiropractic manipulation followed by heat therapy would be the most effective protocol in the treatment of cervical facet syndrome. Method: Forty-five participants were recruited by means of advertisements posted around the University of Johannesburg Doornfontein campus and surrounding businesses. Only those participants who conformed to the inclusion criteria were accepted to form a part of the study. The forty-five participants were randomly placed into three groups of fifteen each. Procedure: Group 1 received chiropractic manipulation only as their treatment protocol. Group 2 received chiropractic manipulation followed by heat therapy as their treatment protocol and group 3 received chiropractic manipulation followed by cryotherapy as their treatment protocol. Each participant received six treatments over a two week period and attended a follow-up consultation in the third week. The follow-up consultation was used to assess the lasting effects of the treatment protocol. Results: The objective data in the form of cervical range of motion was obtained by means of the Cervical Range of Motion instrument. The subjective data was collected by means of the Vernon-Mior Neck Pain and Disability Index and the Numerical Pain Rating Scale. At the end of the trial, statistical analysis was performed to determine whether one treatment protocol was more effective compared to the other treatment protocols. The results indicated that group 2 (Chiropractic manipulation followed by heat therapy) proved to be the most effective treatment protocol. Although the other treatment protocol as well as the control group showed good objective results. Subjective results showed that although all three groups showed statistically significant results, group 2 showed the best results. Thus it is noted that in order to achieve a potentially lasting increase in range of motion and a decrease in pain and disability, the treatment protocol used for group 2 should be the treatment of choice. Conclusion: Trends indicate the most effective treatment protocol in the treatment of cervical facet syndrome is when chiropractic manipulation is followed by heat therapy. The advantage of this combination is that each treatment modality is used to its full potential, thereby providing the patient with the best results in terms of lasting benefits.