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  1. Kate Kerr
  1. University of Nottingham

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    This report again highlights the risks inherent in the application of a widely accepted and easily accessible modality which has recently been raised in this journal.1 It is difficult to find definitive recommendations in the literature on the frequency and duration of cold application, with few studies examining the effect of cold on blood flow over time.2 Ho et al2 found decreases in blood flow after five minutes of cold application, which were enhanced threefold to fourfold with applications up to 25 minutes. Most studies recommend application for between 20 and 30 minutes.3–5 However, case reports indicate a risk of nerve damage if the application is prolonged or over superficial nerve roots, or in athletes with little subcutaneous fat.6–8 It appears that, in the previously reported case,1 the weight of the limb on the ice pack with no intervening material may have compromised circulation beyond safe limits, and, in the present report, the prolonged application (>40 minutes) coupled with the weight of the frozen chips had the same effect.

    The Association of Chartered Physiotherapists in Sports Medicine recently published guidelines on the application of PRICE for soft tissue injuries,9 which provide the following recommendations.

    1. The most effective duration of application is 20–30 minutes, with a maximum safe period of 30 minutes.

    2. A damp towel should be placed between the cooling agent and the skin.

    3. Care should be taken with the application of ice (or cooling agent) on areas with little subcutaneous fat or muscle, and in the region of superficial nerves, with a maximum cooling period of 10 minutes.


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