Archives of Physical Medicine and Rehabilitation
Volume 84, Issue 6 , Pages 849-853, June 2003

Complications from therapeutic modalities: results of a national survey of athletic trainers1

  • Scott F Nadler, DO

      Affiliations

    • Department of Physical Medicine and Rehabilitation, UMDNJ-NJ Medical School, Newark, NJ, USA
    • Corresponding Author InformationReprint requests to Scott F. Nadler, DO, Dept of PM&R, UMDNJ-NJ Medical Sch, 90 Bergen St, Ste 3100, Newark, NJ 07103 USA
    • ,
  • Michael Prybicien, ATC

      Affiliations

    • Department of Physical Education, St Peter’s College, Newark, NJ, USA
    • ,
  • Gerard A Malanga, MD

      Affiliations

    • Department of Physical Medicine and Rehabilitation, UMDNJ-NJ Medical School, Newark, NJ, USA
    • Kessler Institute for Rehabilitation, West Orange, NJ, USA
    • ,
  • Dan Sicher, ATC, MD

      Affiliations

    • Department of Physical Education, St Peter’s College, Newark, NJ, USA

Article Outline

Abstract 

Nadler SF, Prybicien M, Malanga GA, Sicher D. Complications from therapeutic modalities: results of a national survey of athletic trainers.

Objective:

To understand better the frequency and type of complications encountered by athletic trainers.

Design:

A descriptive questionnaire.

Setting:

Athletic training facilities at the high school, college, and professional levels, as well as physical therapy clinics.

Participants:

A total of 3012 certified athletic trainers employed in above-mentioned settings.

Interventions:

Not applicable.

Main Outcome Measures:

Frequency and types of complications encountered for different modalities were computed. Primary modality type used and frequency of complications in different settings were explored.

Results:

Of the 3012 surveyed, 905 (30%) responded, 26% of whom reported a complication; 362 total complications were documented. Cryotherapy accounted for 42% of complications, with allergic reactions (n=86), burns (n=23), and intolerance/pain (n=16) most commonly listed. Electric stimulation accounted for 29% of complications, with skin irritation (n=41), burns (n=40), and intolerance/pain (n=18) most commonly listed. Therapeutic heat accounted for 22% of complications; therapeutic exercise accounted for 7% of complications.

Conclusions:

Compared with documented complications in the peer-reviewed literature, our survey results differed vastly with regard to the complications encountered. This may reflect a learning phenomenon, a shift in modality usage, or a general underreporting of complications.

Keywords:  Athletic injuries, Cryotherapy, Rehabilitation, Sports

 

THERAPEUTIC MODALITIES ARE commonly used in the treatment of musculoskeletal injuries. Despite the frequency with which they are used, limited information exists in the peer-reviewed literature regarding complications from these modalities. In a MEDLINE search from 1963 to 2002, 333 complications were documented in various case reports in the peer-reviewed literature.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 Of those documented, 297 complications were associated with the use of whirlpools or hot tubs and included dermatitis, folliculitis, systemic infections (Pontiac fever), urinary tract infections, and pneumonia.4, 7, 9, 11, 12, 13, 14, 15, 16, 20, 23, 24, 27 Of the remaining 36 reported complications, 17 were burns secondary to the use of heating pads8, 12, 21, 25, 28, 29 and 19 were caused by cryotherapy, with 13 of these cases specified as nerve injuries.1, 6, 10, 17, 18, 22, 30, 31 According to information from the Consumer Products Safety Commission, it is estimated that more than 1500 burns secondary to the use of electric heating pads are treated in emergency rooms each year, and an average of 8 deaths per year are associated with the use of heating pads.19, 28 Most of these complications are secondary to self-administration of high-intensity heating modalities, and reports of these complications have never been published in the peer-reviewed literature.19, 28

Complications from modality use may be more common than reported in the peer-reviewed literature. A survey instrument was created to attempt to gain a better understanding of the relative frequency of complications from modalities. Athletic trainers were the chosen study population, because they are integral members of the athletic health care team and commonly use therapeutic modalities in treating athletic injuries.32, 33

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Methods 

Surveys were mailed to 3012 certified athletic trainers from the National Association of Athletic Trainers directory of certified athletic trainers. Trainers working at the high school, college, and professional level, as well as those employed in physical therapy (PT) clinics, were included in the survey. There were no exclusion criteria from participation in the survey. The survey incorporated information regarding general demographics, including setting and status of employment (fig 1). Respondents were questioned about the use of therapeutic modalities in their capacity as athletic trainers and were asked to list any complications resulting from that use. A self-addressed stamped envelope was provided in the survey packet to allow for ease of return. No monetary or other reward was provided for participating in the survey process.

Statistical analysis 

Analysis was performed to obtain a breakdown of the numbers and types of complications encountered for different modalities. Chi-square analysis was used to determine the differences in the primary modality type used and frequency of complications encountered in different settings. Analysis was also performed to determine whether frequency of complications might vary with the position and experience of the athletic trainer.

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Results 

Of the 3012 trainers mailed surveys, 30% (905/3012) responded. Of these respondents, 78% (701/905) were head or assistant trainers, 16% (142/905) were graduate student assistants, and 18% (162/905) were specified as “other” positions. Respondents were employed in the following settings: 37% (337/905) worked in high schools, 30% (270/905) were employed within a college, 28% (250/905) worked within a PT clinic, and 3% (30/905) were in the professional team setting.

As shown in figure 2, modalities reported as commonly used were ice (30%), therapeutic exercise (22%), hydrocollator packs (18%), electric stimulation (15%), and other (15%). Other modalities, not used as commonly, were vapocoolant sprays (<1%), heating pads (1%), warm whirlpool (3%), and fluidotherapy (<1%). Chi-square analysis indicated that ice was significantly more likely to be a first choice of athletic trainers working in high school (91%) and college (85%) settings than it was for those working in PT settings (40%) (P=.0001). Therapeutic exercises were a more common first choice in the PT clinic setting (36%), compared with high school (6%) or college (8%) settings (P=.0001). Electric stimulation was a more common supplementary therapy in college (22%) and PT settings (21%) than in the high school setting (7%) (P=.0001). The number of complications in a given setting for a particular modality was related to how often that modality was used. Overall, fewer complications (P=.0003) were reported in the high school setting (18%) than in college (31%), PT clinic (31%), and professional team (36%) settings.

Of 905 respondents, 233 (26%) reported a complication with therapeutic modalities, from a total of 362 complications. Cryotherapy, which encompasses ice, cold packs, cold whirlpool, or cryocuff, accounted for 42% of all complications. Electric stimulation, including iontophoresis, accounted for 29% of complications. Therapeutic heat, including hot packs, electric heating pads, hydrocollator packs, whirlpool, paraffin, and ultrasound, accounted for 22% of complications. Therapeutic exercise accounted for 7% of reported complications. Fig 3, Fig 4, Fig 5, Fig 6 provide details of complications for each category of modality. Trainers did not specify 8 of the 362 complications, and these 8 are not included in the figures. Complications most commonly associated with cryotherapy included allergic reactions (n=86), burns (n=23), and intolerance/pain (n=16) (fig 3). Skin irritation (n=41), burns (n=40), and intolerance/pain (n=18) were the most common complications described with electric stimulation (fig 4). Burns (n=41), skin rash (n=19), and intolerance/pain (n=15) were the most common complications with therapeutic heat (fig 5). Complications most commonly associated with therapeutic exercise were pain (n=16) and injury aggravation (n=4) (fig 6).

The relative experience of trainers may have influenced the frequency of complications. Head athletic trainers, on average, reported the lowest (P=.03) frequency of complications (22%); the highest incidence of complications (33%) was reported by assistant athletic trainers.

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Discussion 

Complications secondary to modality use are poorly documented in the peer-reviewed literature. This survey was performed to develop a stronger understanding of modality-induced complications, to better educate those who use modalities about some of the potential side effects encountered with use. Of the responding trainers, 26% reported that they had encountered at least 1 complication from modalities during the course of treatment of athletes. Of particular interest were the 362 complications documented, which included burns, frostbite, allergic reactions, a syncopal episode, and an arrhythmia. These complications differed vastly from those encountered in a MEDLINE literature search, of which most were infections secondary to whirlpool usage.4, 7, 9, 11, 13, 14, 15, 16, 20, 23, 24, 27 Athletic trainers noted limited complications secondary to whirlpool use, which may indicate a learning effect from the existing body of literature or possibly that athletic trainers do not use heated whirlpools with great frequency in the course of treating acute athletic injuries. We believe it is a combination of the 2 phenomena. One other interesting comparison was in the area of cryotherapy-induced complications. Of the 19 cryotherapy-induced complications in the literature, 13 were nerve-related injuries and 1 case involved frostbite.1, 2, 6, 17, 18, 22, 31 No cases of cryotherapy-induced nerve injury were encountered in our survey, which either implies a learning effect or that these injuries are underreported or missed during the course of assessing athletic injuries.1, 2, 6, 17, 18, 22, 31

Overall, responding athletic trainers indicated a greater frequency of complications secondary to the use of cryotherapy, which may have been expected because of their reported greater use of this modality. However, therapeutic exercise showed a low complication rate despite the great frequency with which it was used. The greater use of therapeutic exercises as opposed to physical modalities by athletic trainers working in PT clinics may imply differences in practice style between physical therapists and athletic trainers or, more simply, a less acute population being treated.

There were various sources of potential error in this study. Our response rate was only 30% and could create the possibility for response bias. Because our sample size was reasonably large and questions were geared toward more factual information as opposed to rating scales, we believe that response bias is less likely but may still be a limitation of the study. Questions pertaining to practice setting, experience level, and number of years as a practicing trainer may be confounding factors that influenced results. Thus, a future study, with more data points, is needed to stratify thoroughly the rate of complications in different settings and for health care providers of various backgrounds, experience levels, and years in practice. Additionally, the validity and reliability of our survey instrument will need to be proven before its use in future studies, and the lack of such proof is a weakness in our present research design. A future study will need to address, in greater detail, the reasons behind the underreporting of complications, along with the inclusion of a wider variety of modalities and more specifics with respect to severity of complications. To improve response rate, follow-up mailings and/or a telephone survey of nonresponders will need to be done.

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Conclusions 

The peer-reviewed literature is deficient with regard to the documentation of complications from therapeutic modalities. In this survey, a high percentage of trainers reported the occurrence of 1 or more complications in the course of treating athletes. Compared with other peer-reviewed reports, our results showed major differences in the types of complications encountered and in the modalities that caused them. This difference may reflect a learning phenomenon, a shift in modality use, or a general underreporting of complications.

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Acknowledgements 

The authors would like to thank Ariz Mehta and Phil Landes, MD, for their contributions to this manuscript.

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References 

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  • 1 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

PII: S0003-9993(02)04955-9

doi:10.1016/S0003-9993(02)04955-9

Archives of Physical Medicine and Rehabilitation
Volume 84, Issue 6 , Pages 849-853, June 2003

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