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0196-601 1/88/0909-0301$02.00/0 THEJOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright Q 1988 by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association ICE AND HIGH VOLTAGE PULSED STIMULATION IN TREATMENT OF ACUTE LATERAL ANKLE SPRAINS* SUSAN MICHLOVITZ, MS, PT,t WAYNE SMITH, MEd, PT, ATC* MARY WATKINS, MS, PTt The purpose of this investigation was to compare ice versus ice and high voltage pulsed stimulation (HVPS) for the treatment of
  01 96-601 1 88/0909-0301 02.00/0 THE JOURNAL F ORTHOPAEDIC ND SPORTS HYSICAL HERAPY Copyright Q 1988 by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association ICE AND HIGH VOLTAGE PULSED STIMULATION IN TREATMENT OF ACUTE LATERAL ANKLE SPRAINS SUSAN MICHLOVITZ, MS, PT,t WAYNE SMITH, MEd, PT, ATC* MARY WATKINS, MS, PTt The purpose of this investigation was to compare ice versus ice and high voltage pulsed stimulation HVPS) for the treatment of ankle sprains. Thirty young adult subjects with grade I or I1 lateral ankle sprains were included in this study. Subjects received treatment within 30 hours following injury and were treated once daily for three days. Group I N 10) received ice for 30 minutes; group I1 N 10) received combination ice and HVPS 28 pps, negative polarity, current to comfort without contraction) for 30 minutes, and group N 10) received ice and HVPS 80 pps, negative polarity, 30 minutes). All groups showed a tendency toward a decrease in pain, decrease in edema, and increase in ankle dorsiflexion following treatment. ANOVA for edema and dorsiflexion changes revealed that there were no significant differences in treatment effects among groups. HVPS, as utilized, did not further affect pain, edema, or range of dorsiflexion in the treatment of acute lateral ankle sprains. High voltage pulsed stimulation (HVPS) is MATERIALS AND METHODS inthe treatment :E, _E Subjects were 30 healthy military recruits rang- trauma, particularly for edema control. ing in age from 18 to 38, who sustained a grade Limited quantitative data are available demon- I or lateral ankle sprain between and 28 hours strating the effects of this electrotherapeutic prior to initial physical therapy assessment and agent on acute edema. A recent review of the treatment. literature has suggested that HVPS protocols are The patients were randomly assigned to one of not well developed or con~istent.'~ he purpose three treatment groups. There were 10 in each of this study was to evaluate the effects of HVPS group. Group I received an ice pack circumferen- using negative polarity continuous modulation at tially wrapped about the ankle for 30 minutes. 28 pulses per second (pps) or at 80 pps in addition Group ll received combination ce pack and HVPS to a standardized regimen of ice, elevation and at 28 PpS CO~~~~UOUS odulation for 30 I'tlin~tes. compression on ankle edema, range of motion Group received the same treatment as group (ROM), and pain during the acute phase following except that the was set at 80 pps. Both grades I and II lateral ankle sprains. It was hy- 28 and 80 pps have been frequencies suggested at seminars, in company printed protocols, and pothesized that HVPS would contribute to a re- by practicing clinicians. n EGS model (Elec- duction in edema, increased ROM, and a reduc- tro-Med Miami FL) was used for the in pain Over and above the effects Of electrical stimulation. Treatments were given once compression, and elevation. a day for 3 days. The assessment consisted of volumetric meas- 'The views expressed in this article are those of the authors and do urements of the foot and ankle, ROM in dorsiflex- not reflect the official policy or position of the U.S. Public Health Sewice. ion and perceived pain. VO~U~~ nd ROM Were Hahnemann University, Programs n Physical Therapy, Mail Stop 502. pre-treatment and post-treatment on Broad & Vine Streets, Philadelphia, PA 191 02-1 192. *~t he time of data collection Wayne Smith was with the Physical days 1 and 3. Pain Was assessed prior to and Therapy Department. USCG Training Center, Cape May, NJ 08204. He following the treatment on day 1 is currently with the USCG Support Center, Health Sewices Division. Government Island, Alameda, CA 94501. Volumetric measurements were determined by 301  302 MICHLOVI TZ ET AL JOSPT Vol. 9 No. 9 the water displacement technique using a Lucite tank (Volumeters Unlimited, Idyllwild, CA) and a graduated cylinder. The patient was seated, then placed the involved foot at the bottom of the tank with the heel against the back wall. After the foot was situated in the tank the obturator cube was put in place to improve accuracy of measurement by displacing more water. The displaced water was collected in a large receptacle, then poured into a large narrow graduated cylinder for more precise measurement. Reliability of measurement of this volumeter was determined to be +25 ml on an average of 10 trials on one uninjured sub- ject. Active dorsiflexion was measured with a goni- ometer with the patient prone-lying and the knee flexed to 90'. The patients were asked to rate the intensity of pain using a horizontal numerical 10 point scale. They were asked to choose one number to indi- cate the level of pain. A rating of 10 indicated the most severe pain. TREATMENT PROTOCOL All patients were positioned in supine with the affected lower extremity elevated to 45 . A 3 inch by 3 inch carbon silicone impregnated rubber electrode was applied to each side of the ankle and held in place with an elastic wrap. Wet gauze was placed between the electrode and the skin. Electrodes on the ankle were negative in polarity and served as the active electrode. The dispersive electrode (8 inches by 10 inches) was placed on the low back and held in place by body weight. An ice pack was then applied around the ankle and held in place with an elastic wrap. For the patients in group I he current was not turned on. For both group II and group Ill patients receiving HVPS with negative polarity, intensity was turned up to the point of muscle contraction and then turned down to just below palpable contraction for the duration of the 30 minute treatment. These treatment protocols were administered once a day for 3 days. At the end of each treatment session, the foot and ankle were ace wrapped. The patients were instructed and trained in the use of axillary crutches. They participated in classroom activi- ties, but sat on the sidelines during field activities. DATA ANALYSIS Volume and ROM were analyzed using a one way analysis of variance. Descriptive statistics are presented for the analysis of perceived pain. Sig- nificance was accepted at p < 0.05. RESULTS There were no significant differences in duration of injury among the three groups (Table 1). There were no significant differences between the groups in volumetric or ROM measures. Fol- lowing the first treatment, group I had a mean decrease in volume of -1 2 & 1 1 (Table 2). Further, in groups II and Ill the volume changes were 22 + 28 and 28 + 12 ml, respectively. At the end of the third treatment, the average decrease in volume for all groups was between 32.5 + 28 and 38 + 6 from the initial pre-treatment measure on day 1. After the third treatment, no subjects in group I had an increase in volume from the pre- treatment measure, whereas one subject in group TABLE Time since injury of all groum Treatment' Time since injury (in hours, mean and SD Ice N 10) 10f 11 Ice HVPS 28 pps N 10) 8k9 Ice HVPS 80 pps N 10) 9f9 Source Sum of Mean sauares df sauare Ft Between 34.4199 2 17.21 .I67746 Within 2564.89 25 102.596 Total 2599.31 'One-way analysis of variance of time since injury of all 3 groups. Critical F p 0.05); 3.39. TABLE Changes in foot and ankle volume displacement n millimeters Following first Following third Treatment treatment' treatmentt (millimeters, (millimeters, mean, and SD mean, and SD Ice (N 10) -12fll -32228 Ice + HVPS 28 pps N 10) -22 28 -38 56 lce+HVPS80~~s N=10) -28f12 -35+39 Sum of df Mean Source squares square F* Between 920.071 2 460.036 1.36032 Within 9130.9 27 338.180 Total 10051 Between 161.223 2 80.6113 .0453107 Within 46256.1 26 1779.08 Total 4641 7.3 One-way ANOVA of foot and ankle volume displacement after first treatment. One-way ANOVA of foot and ankle volume displacement after third treatment. Critical F p 0.05); 3.39.  JOSPT March 1988 ICE AND HVPS IN TREATMENT OF ANKLE SPRAINS 303 II and two subjects in group Ill had increases in volume over the initial values. Although all groups had an increase in ankle dorsiflexion over the course of the 3 days of treatment, the changes were minimal (Table 3). After the first treatment the mean increase and standard deviation in dorsiflexion were 1 1 in group I and 3 4 and 4 + 3 in groups II and Ill, respectively. Following the third treatment, the mean increases were 7 -1- 2, 10 + 7 nd 8 + 3O, respectively. The changes among groups follow- ing both the first treatment and the third treatment were not significantly different. Scores for perceived pain were determined only before and after the first treatment. The mean pre-treatment pain score was 5.7 for the ice only group and following the first treatment a mean of 3.2, resulting in a mean decrease in pain of 2.5 points (Table 4). Both groups treated with ice and HVPS had decreases in pain from pre- to post- treatment of 3.65 and 3.70. Eight of 10 patients in the ice treated group and 4 out of 10 in the HVPS at 28 and 80 pps improved from 1-3 points from pre- to post-treatment categorized by us as TABLE 3 Change in active ankle dorsiflexion ROM (in degrees) Following first Following third Treatment treatment* treatmentt in degrees, in degrees, mean. and SD mean. and SD Ice N = 10) 1 +1 7+2 Ice HVPS 28 pps (N = 10) 3 + 4 10 + 7 Ice HVPS 80 pps N = 10) 4+3 8+3 Source Sum of Mean sauares df sauare FS Between 44.8665 2 22.4333 2.22601 Within 272.1 27 10.0778 Total 31 6.967 Between 53.3678 2 26.6839 1.3007 Within 533.389 26 20.515 Total 586.757 ne-way analysis of variance of active ankle dorsiflexion after first treatment. One-way analysis of variance of active ankle dorsiflexion after third treatment. Critical F (p = 0.05); 3.39. TABLE 4 Perceived pain (0- 10 point scale) Following Treatment Pretreatment first Change in pain treatment Ice N = 10) 5.7 2.2 3.2 + 1.9 -2.50 1.43 Ice + HVPS 28 pps 6.1 + 2.2 2.2 + 1.5 -3.65 + 2.10 N= 10) Ice HVPS 80 pps 6.2 + 2.5 2.6 + 1.3 -3.70 + 2.36 N = 10) slight improvement (Table 5). Two out of 10 ice treated and 6 out of 10 treated with electrical stimulation improved from four to seven points, or moderately improved. Those treated with elec- trical stimulation tended to show a greater reduc- tion in pain, but due to the subjective nature of the pain evaluation and the small number of sub- jects, statistical analysis was not performed. DISCUSSION The conventional management of ankle sprains is ice, compression, and elevation. Over the last decade, HVPS has often been included with this treatment paradigm. The proposed rationale for the inclusion of HVPS was to decrease edema and pain, thus reducing the inflammatory re- sponse. High voltage is used because of its neg- ligible chemical effects7 and low average current, thus offering the patient increased comfort level over traditional low voltage stimulation. The mechanisms of action of electrical stimu- lation for edema reduction are unknown but may be through an electrophoretic effect or muscle pumping action.4310 With edema, interstitial pro- teins and fluids increase. Therapy should be geared toward restoring normal osmotic bal- ances. We chose to look at the postulate that high voltage pulsed stimulation can cause move- ment of fluid, serum protein, and blood cells with- out muscular contraction. It is important to realize, though, that we did not directly measure fluid and cellular shifts but measured the clinical expression of such changes, i.e., distal limb volume. But, with the parameters reported in this study the HVPS did not add to the edema control resulting from the ice, compression, and elevation. Electrical stimulation is a well accepted proce- dure for pain controL2 There was some evidence from the descriptive data in this study that the addition of ES to treatment did provide an addi- tional pain relief. The stimulus characteristics used were similar to those for conventional TENS.6 Other adaptions in the treatment protocol could be 1 treat with postive polarity over the injured area, 2 alter polarity through the treatment ses- TABLE 5 Effect of treatment on perceived pain Degree of improvement Ice + Ice + change in pain score) Ice HVPS 28 pps HVPS 8 pps 0-3 (slight) N=8 N=4 N=4 4-7 (moderate) N = 2 N = 6 N=6  304 MlCHLOVlTZ T AL JOSPT Vol 9 o 9 sion, or 3) place both all) electrodes over the injured area to concentrate current more in the area of injury. These aforementioned changes may perhaps enhance treatment effects. In addi- tion, increasing treatment duration or the number of treatment sessions per day could perhaps have produced a different outcome. Pain and ROM can be useful data to collect when looking at functional outcome but this study was limited to 72 hour data collection. The re- search question in this study was limited to the first 3 days and did not ask the broader question regarding final outcome. The changes in volume measured with the vol- umeter were very small. With grade I and I  ankle sprains the figure-of-eight girth measure may be more specific to the area of swelling than is volu- metric~. CONCLUSION Ice and HVPS at 28 and 80 pps tend to produce a decrease in foot and ankle volume, an increase in range of motion in dorsiflexion, and a decrease in pain. However, there were no significant differ- ences shown among the groups studied in any measured parameter. Therefore, within the limits of this subject sample, it was concluded that HVPS did not further enhance the effects of ice, compression, and elevation. The authors would like to thank Captain Robert Parrene for his clinical assistance, Gabriella Ship for her assistance in research design, and William 8 McBeth for providing us with electrodes. REFERENCES 1. Alon G High Voltage Stimulation: A Monograph. Chattanooga Corporation. 1984 2. Binder SA: Applications of low and high voltage electrotherapeutic currents. In: Wolf SL ed), Electrotherapy Clinics in Physical Ther- apy). New Yotk Churchill Livingston, 1981 3. Crister GR: Sprains and strains treated with Me ultrafaradic M-4 impulse generator. J Fla Med Assoc 40:32-44, 1953 4. Kloth L Electrophoresis in the management of acute soft tissue trauma. Stimulus Section on Clinical Electrophysiology of APTA Newsletter), May 1983 5. Lamboni P, Harris B: The use of ice, airsplints and high voltage galvanic stimulation n effusion reduction. Athl Train 18:23, 1983 6. Mannheimer JS. Lampe G Clinical TENS. Philadelphia: FA Davis Co, 1984 7. Newton RA. Karselis TC: Skin pH following high voltage pulsed galvanic stimulation. Phys Ther 63:1593-1596. 1983 8. Ross CR, Segal D: High voltage galvanic stimulation-An aid to post operative healing. Curr Pod 30:19-25.1981 9. Smith W High galvanic therapy in the symptomatic management of acute tibia1 fracture. Athl Train 16:59-60, 1981 10. Voight ML: Reduction of post traumatic ankle edema with high voltage pulsed galvanic stimulation. Athl Train 19:278-279, 31 1, 1984
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