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A randomized trial comparing intravenous paracetamol, topical lidocaine, and ice application for treatment of pain associated with scorpion stings G Aksel, S Güler, NÖ Dogan and SK Çorbacioglu Hum Exp Toxicol published online 10 October 2014 DOI: 10.1177/0960327114551394 The online version of this article can be found at: http://het.sagepub.com/content/early/2014/09/26/0960327114551394
Published by: http://www.sagepublications.com
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Article
A randomized trial comparing intravenous paracetamol, topical lidocaine, and ice application for treatment of pain associated with scorpion stings
Human and Experimental Toxicology 1–6 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0960327114551394 het.sagepub.com
¨ Dog˘an3 and S¸ K C G Aksel1, S Gu¨ler2, NO ¸ orbaciog˘lu4
Abstract Objective: Appropriate treatment for scorpion-associated pain was not previously studied in detail in the literature. The aim of this study was to compare the efficacy of three treatment modalities in patients with painful scorpion stings using visual analog scale (VAS) scores. Materials and Methods: A randomized study was carried out during a 1-year period in patients with scorpion stings who did not have any systemic signs or symptoms. Patients were treated with intravenous paracetamol, topical lidocaine, or ice application. Pain intensity was evaluated using VAS score at the time of presentation to emergency department and at 30th, 60th, 120th, and 240th minutes. Changes in VAS scores from baseline were recorded. Results: A total of 130 patients were included in the statistical analysis. Significant reduction in pain intensity was observed with topical lidocaine group when compared with the ice application group (p < 0.001) and paracetamol group (p < 0.001) in all selected time intervals. The median reduction in scores at 30 min after therapeutic intervention was 25.0 mm for topical lidocaine, 14.5 mm for ice application, and 10.0 mm for intravenous paracetamol. No adverse events were reported. Discussion: Our results revealed that topical lidocaine is superior to both intravenous paracetamol and local ice application and its effect lasts several hours after envenomation. conclusion: Topical lidocaine is an effective and safe treatment in scorpion sting associated with pain in patients with nonsystemic signs and symptoms. Keywords Scorpions, pain management, pain measurement, emergency medicine (MeSH database)
Introduction Scorpion envenomation is common in tropical and subtropical regions, especially in North Africa, Latin America, India, and the Middle East, where it is seen as a public health problem.1 The epidemiology of scorpion envenomation in the world is poorly known. There are considerable geographical variations at the level of both the incidence and severity.2 Scorpion sting cases are particularly common in the southeastern region of Turkey due to geographical location, climate, and socioeconomic structure. The most important health-threatening scorpions found in Turkey are Androctonus crassicauda, Leiurus
¨ mraniye Training and Department of Emergency Medicine, U Research Hospital, Istanbul, Turkey 2 Department of Emergency Medicine, Ankara Training and Research Hospital, Ankara, Turkey 3 Department of Emergency Medicine, Kocaeli University, Faculty of Medicine, Kocaeli, Turkey 4 Emergency Service, Antakya State Hospital, Antakya, Turkey 1
Corresponding author: ¨ mraniye Training and Research Hospital, Department G Aksel, U of Emergency Medicine, Elmali Mahallesi, Adem Yavuz Caddesi, ¨ mraniye, Istanbul, Turkey. No:1, 34764 U Email: [email protected]
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Human and Experimental Toxicology
quinquestriatus, Mesobuthus gibbosus, and Mesobuthus eupeus species, all of which belong to the Buthidae family.3,4 The main clinical features of scorpion envenomation are localized reactions (e.g. local pain at the sting site radiating along with corresponding dermatomes, mild local edema around the sting site, localized paresthesia, and pruritis) that occur in up to 97% of affected people; systemic manifestations (e.g. fever, sweating, hypertension, and vomiting) are uncommon (3%).5 Cardiorespiratory manifestations, mainly cardiogenic shock and pulmonary edema, are the leading causes of death after scorpion envenomation.6 The clinical picture depends on the anatomical location of the sting, victim’s age, weight, and health status. Most human victims of scorpionism experience local pain or a burning sensation at the site of the sting, but they do not develop general envenomation.7,8 Pain is the most common symptom of localized reactions. Almost all patients have localized pain at presentation, which is the only symptom in most patients.1,9–11 It was reported that local pain was seen in 95.1% of patients in a recent study held in the same region with our study.12 Pain is usually immediate, intense, persistent, with feelings of partial recoveries and relapses.2 Paracetamol has been recommended for pain management for mild envenomation.13 Application of ice and local anesthetic to the area of the sting has also been recommended to reduce pain.14 However, accurate treatment for pain resulting from the scorpion stings was not previously studied in detail in the literature. In this study, we aimed to compare three pain management modalities for scorpion stings in patients without systemic signs and symptoms.
Methods Study design This prospective and randomized study was carried out between October 2011 and November 2012 in a rural hospital in Mardin, a city in the southeast Turkey. The emergency department (ED) of this hospital admits approximately 110,000 patients per year, and admissions with scorpion stings are commonly encountered due to regional features. This study aimed to compare three treatment groups in patients with painful scorpion stings such as intravenous paracetamol, topical lidocaine gel, and ice application. All of the study drugs or applications are currently used for scorpion stings in this ED. The research was
conducted in accordance with the tenets of the Declaration of Helsinki, and patients were asked to sign an informed consent before they enrolled in the study.
Selection of participants The study was carried out in patients with scorpion stings who did not have any systemic signs or symptoms. Inclusion criteria were presentation to the ED due to pain associated with scorpion sting with only localized reactions (e.g. local pain at the sting site radiating along with corresponding dermatomes, mild local edema around the sting site, localized paresthesia, and pruritis), age over 18, and approval to participate in the study by signing the informed consent form. Exclusion criteria included questionable stings, late presentations (over 6 h), age under 18, known allergy to paracetamol, nonsteroidal antiinflammatory drugs or lidocaine, use of any oral/ intravenous analgesic drug within 24 h of ED presentation, refusal to participate in the study, and simultaneous abnormal skin conditions including local infections, ulcerations, and scars. Patients were also excluded if they had systemic signs and symptoms including hemodynamic instability, electrocardiographic abnormality, rapidly progressing local edema, abnormal neurological examination findings, autonomic symptoms (sweating, pallor, salivation, nausea, and vomiting), chest pain, pulmonary edema, or altered mental status.
Study protocol Individuals included in the statistical analysis were allocated randomly in one of the three groups using sealed envelopes such as intravenous paracetamol (Perfalgan1 10 mg/mL, 100 mL, Bristol Myers Squibb, New York City, New York, USA), topical _ Turkey), and lidocaine (Anestol1 pomade %5, Ilsan, ice application. One gram of intravenous paracetamol was given to the paracetamol group and topical 5% lidocaine was applied directly to the sting site over a particular surface area in the lidocaine group. Ice packs were applied to the sting site intermittently for 10 min in ice application group. Ice application was performed 3 times with 10-min intervals. Intravenous paracetamol and topical lidocain were given only once. If pain persisted 30 min after presentation, narcotics were used as rescue medication. Random selection of envelopes and drug administrations were done by two different ED nurses in each
Downloaded from het.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 25, 2014
Aksel et al.
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shift, who were blinded to the study. Pain intensity was evaluated using visual analog scale (VAS) score (0 to 100 mm; 0 ¼ no pain, 100 ¼ worst possible pain) before receiving the chosen treatment modality at baseline and at predetermined time intervals. Patients who were specified to have inadequate pain relief received 50 mg pethidine hydrochloride (Aldolan1 50 mg/mL, 2 mL, Liba, Turkey) for pain control. Historical and demographic features were recorded on a standardized data collection form. The primary outcome measure was change in pain intensity at 30th, 60th, 120th, and 240th minutes. All adverse events were recorded on the study form.
Data analysis SPSS 11.0 (SPSS Inc., Chicago, Illinois, USA) was used for statistical analyses. The Kolmogorov–Smirnov test was used for statistical analysis to verify data normality. Continuous variables were expressed as mean + standard deviation for normally distributed data and median (with minimummaximum values) for nonnormally distributed data. The parametric comparisons for the three groups were performed by analysis of variance, and for nonparametric comparisons, the Kruskal–Wallis test was performed. Homogeneity of variances was tested with Levene’s test. Subgroup analyses were carried out with the Mann–Whitney U test with Bonferroni correction. Categorical variables were evaluated via Pearson’s 2 test and shown with the number of cases and percentages. Statistical significance was assumed for p < 0.05.
Results A total of 181 patients were evaluated in the initial step for eligibility, and 130 patients were included in the statistical analyses (Figure 1). Patients were randomly allocated to paracetamol group (n ¼ 45, 34.6%), topical lidocaine group (n ¼ 43, 33.1%), and ice application group (n ¼ 42, 32.3%). Main demographic characteristics and initial vital signs are shown in Table 1. All the patients were discharged from ED after at least a 4-h observation period, and no complications or adverse events were observed in the follow up. Scorpion sting sites were upper extremity (60.0%), lower extremity (35.4%), and torso (4.6%). While 90 patients (69.2%) presented to ED within the first 30 min after scorpion sting, 25 patients presented at the 30th–60th minutes period, and 15 patients after 1 h. There was no statistically significant relationship
Figure 1. Patient flow chart.
between the presentation time to ED and the treatment modality (p ¼ 0.092). According to local symptoms, 98 patients (75.4%) reported local paresthesia, 42 patients (32.3%) local swelling, and 10 patients (7.7%) pruritus at the sting site. VAS scores were evaluated at presentation (baseline), 30th, 60th, 120th, and 240th minutes. The baseline VAS score of the paracetamol group was 80 mm (60–90), while it was 70 mm in the topical lidocaine group (60–85) and 62.5 mm in the ice application group (50.0–76.3). There was no statistically significant difference between any of the three groups at baseline VAS scores (p ¼ 0.060). Changes in VAS scores are shown in Table 2. A significant reduction in pain intensity was observed in the topical lidocaine group compared with the ice application group (p < 0.001) and the paracetamol group (p < 0.001) at the 30th minute (Figure 2). No statistically significant difference was observed between ice application and paracetamol groups at the 30th (p ¼ 0.624), 60th (p ¼ 0.505), 120th (p ¼ 0.348), and 240th (p ¼ 1.000) minutes. Topical lidocaine was also found superior to other two treatment modalities in specified time intervals for evaluating pain intensity (p < 0.001).
Discussion To our knowledge, this is the first study comparing different treatment modalities in the management of pain resulting from scorpion stings. Findings after
Downloaded from het.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 25, 2014
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Human and Experimental Toxicology
Table 1. Main demographic characteristics and vital signs of patients. Paracetamola Age Male gender Systolic BP (mmHg) Diastolic BP (mmHg) Pulse (beat/min) Respiratory rate (breath/min) Body temperature ( C) Oxygen saturation (%)
34.00 (19–81) 22 (34.9%) 125 (100–170) 80 (60–90) 83.56 + 10.07 13 (11–18) 36.6 (36.0–37.2) 98.0 (95.0–99.0)
Topical lidocainea 31.00 22 120 70 82.28 13 36.7 98.0
(18–70) (34.9%) (100–150) (60–95) + 10.03 (11–17) (36.0–37.5) (95.0–99.0)
Ice applicationa
p Value
40.50 (18–80) 19 (30.2%) 120 (100–165) 75 (60–90) 84.69 + 10.21 13 (11–16) 36.7 (36.1–37.3) 98.0 (95.0–99.0)
0.055 0.859 0.132 0.083 0.547 0.740 0.347 0.914
BP: blood pressure. a n (%) or median (minimummaximum) or mean + SD.
Table 2. Comparison of differences in VAS scores between treatment groups regarding time intervals. Paracetamola Change in Change in Change in Change in
30th minute VAS (mm) 60th minute VAS (mm) 120th minute VAS (mm) 240th minute VAS (mm)
10.00 20.00 35.00 45
(0–40) (0–60) (0–90) (28–62.5)
Topical lidocainea 25.00 40.00 52.00 60
(0–52) (10–70) (10–100) (50–75)
Ice applicationa 14.50 23.00 30.00 45
(0–40) (0–50) (0–70) (33.75–55.25)
p Value
A randomized trial comparing intravenous paracetamol, topical lidocaine, and ice application for treatment of pain associated with scorpion stings G Aksel, S Güler, NÖ Dogan and SK Çorbacioglu Hum Exp Toxicol published online 10 October 2014 DOI: 10.1177/0960327114551394 The online version of this article can be found at: http://het.sagepub.com/content/early/2014/09/26/0960327114551394
Published by: http://www.sagepublications.com
Additional services and information for Human & Experimental Toxicology can be found at: Email Alerts: http://het.sagepub.com/cgi/alerts Subscriptions: http://het.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Oct 10, 2014 What is This?
Downloaded from het.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 25, 2014
Article
A randomized trial comparing intravenous paracetamol, topical lidocaine, and ice application for treatment of pain associated with scorpion stings
Human and Experimental Toxicology 1–6 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0960327114551394 het.sagepub.com
¨ Dog˘an3 and S¸ K C G Aksel1, S Gu¨ler2, NO ¸ orbaciog˘lu4
Abstract Objective: Appropriate treatment for scorpion-associated pain was not previously studied in detail in the literature. The aim of this study was to compare the efficacy of three treatment modalities in patients with painful scorpion stings using visual analog scale (VAS) scores. Materials and Methods: A randomized study was carried out during a 1-year period in patients with scorpion stings who did not have any systemic signs or symptoms. Patients were treated with intravenous paracetamol, topical lidocaine, or ice application. Pain intensity was evaluated using VAS score at the time of presentation to emergency department and at 30th, 60th, 120th, and 240th minutes. Changes in VAS scores from baseline were recorded. Results: A total of 130 patients were included in the statistical analysis. Significant reduction in pain intensity was observed with topical lidocaine group when compared with the ice application group (p < 0.001) and paracetamol group (p < 0.001) in all selected time intervals. The median reduction in scores at 30 min after therapeutic intervention was 25.0 mm for topical lidocaine, 14.5 mm for ice application, and 10.0 mm for intravenous paracetamol. No adverse events were reported. Discussion: Our results revealed that topical lidocaine is superior to both intravenous paracetamol and local ice application and its effect lasts several hours after envenomation. conclusion: Topical lidocaine is an effective and safe treatment in scorpion sting associated with pain in patients with nonsystemic signs and symptoms. Keywords Scorpions, pain management, pain measurement, emergency medicine (MeSH database)
Introduction Scorpion envenomation is common in tropical and subtropical regions, especially in North Africa, Latin America, India, and the Middle East, where it is seen as a public health problem.1 The epidemiology of scorpion envenomation in the world is poorly known. There are considerable geographical variations at the level of both the incidence and severity.2 Scorpion sting cases are particularly common in the southeastern region of Turkey due to geographical location, climate, and socioeconomic structure. The most important health-threatening scorpions found in Turkey are Androctonus crassicauda, Leiurus
¨ mraniye Training and Department of Emergency Medicine, U Research Hospital, Istanbul, Turkey 2 Department of Emergency Medicine, Ankara Training and Research Hospital, Ankara, Turkey 3 Department of Emergency Medicine, Kocaeli University, Faculty of Medicine, Kocaeli, Turkey 4 Emergency Service, Antakya State Hospital, Antakya, Turkey 1
Corresponding author: ¨ mraniye Training and Research Hospital, Department G Aksel, U of Emergency Medicine, Elmali Mahallesi, Adem Yavuz Caddesi, ¨ mraniye, Istanbul, Turkey. No:1, 34764 U Email: [email protected]
Downloaded from het.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 25, 2014
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Human and Experimental Toxicology
quinquestriatus, Mesobuthus gibbosus, and Mesobuthus eupeus species, all of which belong to the Buthidae family.3,4 The main clinical features of scorpion envenomation are localized reactions (e.g. local pain at the sting site radiating along with corresponding dermatomes, mild local edema around the sting site, localized paresthesia, and pruritis) that occur in up to 97% of affected people; systemic manifestations (e.g. fever, sweating, hypertension, and vomiting) are uncommon (3%).5 Cardiorespiratory manifestations, mainly cardiogenic shock and pulmonary edema, are the leading causes of death after scorpion envenomation.6 The clinical picture depends on the anatomical location of the sting, victim’s age, weight, and health status. Most human victims of scorpionism experience local pain or a burning sensation at the site of the sting, but they do not develop general envenomation.7,8 Pain is the most common symptom of localized reactions. Almost all patients have localized pain at presentation, which is the only symptom in most patients.1,9–11 It was reported that local pain was seen in 95.1% of patients in a recent study held in the same region with our study.12 Pain is usually immediate, intense, persistent, with feelings of partial recoveries and relapses.2 Paracetamol has been recommended for pain management for mild envenomation.13 Application of ice and local anesthetic to the area of the sting has also been recommended to reduce pain.14 However, accurate treatment for pain resulting from the scorpion stings was not previously studied in detail in the literature. In this study, we aimed to compare three pain management modalities for scorpion stings in patients without systemic signs and symptoms.
Methods Study design This prospective and randomized study was carried out between October 2011 and November 2012 in a rural hospital in Mardin, a city in the southeast Turkey. The emergency department (ED) of this hospital admits approximately 110,000 patients per year, and admissions with scorpion stings are commonly encountered due to regional features. This study aimed to compare three treatment groups in patients with painful scorpion stings such as intravenous paracetamol, topical lidocaine gel, and ice application. All of the study drugs or applications are currently used for scorpion stings in this ED. The research was
conducted in accordance with the tenets of the Declaration of Helsinki, and patients were asked to sign an informed consent before they enrolled in the study.
Selection of participants The study was carried out in patients with scorpion stings who did not have any systemic signs or symptoms. Inclusion criteria were presentation to the ED due to pain associated with scorpion sting with only localized reactions (e.g. local pain at the sting site radiating along with corresponding dermatomes, mild local edema around the sting site, localized paresthesia, and pruritis), age over 18, and approval to participate in the study by signing the informed consent form. Exclusion criteria included questionable stings, late presentations (over 6 h), age under 18, known allergy to paracetamol, nonsteroidal antiinflammatory drugs or lidocaine, use of any oral/ intravenous analgesic drug within 24 h of ED presentation, refusal to participate in the study, and simultaneous abnormal skin conditions including local infections, ulcerations, and scars. Patients were also excluded if they had systemic signs and symptoms including hemodynamic instability, electrocardiographic abnormality, rapidly progressing local edema, abnormal neurological examination findings, autonomic symptoms (sweating, pallor, salivation, nausea, and vomiting), chest pain, pulmonary edema, or altered mental status.
Study protocol Individuals included in the statistical analysis were allocated randomly in one of the three groups using sealed envelopes such as intravenous paracetamol (Perfalgan1 10 mg/mL, 100 mL, Bristol Myers Squibb, New York City, New York, USA), topical _ Turkey), and lidocaine (Anestol1 pomade %5, Ilsan, ice application. One gram of intravenous paracetamol was given to the paracetamol group and topical 5% lidocaine was applied directly to the sting site over a particular surface area in the lidocaine group. Ice packs were applied to the sting site intermittently for 10 min in ice application group. Ice application was performed 3 times with 10-min intervals. Intravenous paracetamol and topical lidocain were given only once. If pain persisted 30 min after presentation, narcotics were used as rescue medication. Random selection of envelopes and drug administrations were done by two different ED nurses in each
Downloaded from het.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 25, 2014
Aksel et al.
3
shift, who were blinded to the study. Pain intensity was evaluated using visual analog scale (VAS) score (0 to 100 mm; 0 ¼ no pain, 100 ¼ worst possible pain) before receiving the chosen treatment modality at baseline and at predetermined time intervals. Patients who were specified to have inadequate pain relief received 50 mg pethidine hydrochloride (Aldolan1 50 mg/mL, 2 mL, Liba, Turkey) for pain control. Historical and demographic features were recorded on a standardized data collection form. The primary outcome measure was change in pain intensity at 30th, 60th, 120th, and 240th minutes. All adverse events were recorded on the study form.
Data analysis SPSS 11.0 (SPSS Inc., Chicago, Illinois, USA) was used for statistical analyses. The Kolmogorov–Smirnov test was used for statistical analysis to verify data normality. Continuous variables were expressed as mean + standard deviation for normally distributed data and median (with minimummaximum values) for nonnormally distributed data. The parametric comparisons for the three groups were performed by analysis of variance, and for nonparametric comparisons, the Kruskal–Wallis test was performed. Homogeneity of variances was tested with Levene’s test. Subgroup analyses were carried out with the Mann–Whitney U test with Bonferroni correction. Categorical variables were evaluated via Pearson’s 2 test and shown with the number of cases and percentages. Statistical significance was assumed for p < 0.05.
Results A total of 181 patients were evaluated in the initial step for eligibility, and 130 patients were included in the statistical analyses (Figure 1). Patients were randomly allocated to paracetamol group (n ¼ 45, 34.6%), topical lidocaine group (n ¼ 43, 33.1%), and ice application group (n ¼ 42, 32.3%). Main demographic characteristics and initial vital signs are shown in Table 1. All the patients were discharged from ED after at least a 4-h observation period, and no complications or adverse events were observed in the follow up. Scorpion sting sites were upper extremity (60.0%), lower extremity (35.4%), and torso (4.6%). While 90 patients (69.2%) presented to ED within the first 30 min after scorpion sting, 25 patients presented at the 30th–60th minutes period, and 15 patients after 1 h. There was no statistically significant relationship
Figure 1. Patient flow chart.
between the presentation time to ED and the treatment modality (p ¼ 0.092). According to local symptoms, 98 patients (75.4%) reported local paresthesia, 42 patients (32.3%) local swelling, and 10 patients (7.7%) pruritus at the sting site. VAS scores were evaluated at presentation (baseline), 30th, 60th, 120th, and 240th minutes. The baseline VAS score of the paracetamol group was 80 mm (60–90), while it was 70 mm in the topical lidocaine group (60–85) and 62.5 mm in the ice application group (50.0–76.3). There was no statistically significant difference between any of the three groups at baseline VAS scores (p ¼ 0.060). Changes in VAS scores are shown in Table 2. A significant reduction in pain intensity was observed in the topical lidocaine group compared with the ice application group (p < 0.001) and the paracetamol group (p < 0.001) at the 30th minute (Figure 2). No statistically significant difference was observed between ice application and paracetamol groups at the 30th (p ¼ 0.624), 60th (p ¼ 0.505), 120th (p ¼ 0.348), and 240th (p ¼ 1.000) minutes. Topical lidocaine was also found superior to other two treatment modalities in specified time intervals for evaluating pain intensity (p < 0.001).
Discussion To our knowledge, this is the first study comparing different treatment modalities in the management of pain resulting from scorpion stings. Findings after
Downloaded from het.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 25, 2014
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Human and Experimental Toxicology
Table 1. Main demographic characteristics and vital signs of patients. Paracetamola Age Male gender Systolic BP (mmHg) Diastolic BP (mmHg) Pulse (beat/min) Respiratory rate (breath/min) Body temperature ( C) Oxygen saturation (%)
34.00 (19–81) 22 (34.9%) 125 (100–170) 80 (60–90) 83.56 + 10.07 13 (11–18) 36.6 (36.0–37.2) 98.0 (95.0–99.0)
Topical lidocainea 31.00 22 120 70 82.28 13 36.7 98.0
(18–70) (34.9%) (100–150) (60–95) + 10.03 (11–17) (36.0–37.5) (95.0–99.0)
Ice applicationa
p Value
40.50 (18–80) 19 (30.2%) 120 (100–165) 75 (60–90) 84.69 + 10.21 13 (11–16) 36.7 (36.1–37.3) 98.0 (95.0–99.0)
0.055 0.859 0.132 0.083 0.547 0.740 0.347 0.914
BP: blood pressure. a n (%) or median (minimummaximum) or mean + SD.
Table 2. Comparison of differences in VAS scores between treatment groups regarding time intervals. Paracetamola Change in Change in Change in Change in
30th minute VAS (mm) 60th minute VAS (mm) 120th minute VAS (mm) 240th minute VAS (mm)
10.00 20.00 35.00 45
(0–40) (0–60) (0–90) (28–62.5)
Topical lidocainea 25.00 40.00 52.00 60
(0–52) (10–70) (10–100) (50–75)
Ice applicationa 14.50 23.00 30.00 45
(0–40) (0–50) (0–70) (33.75–55.25)
p Value
