Responsiveness and clinically important differences of the PROMIS short form-depression 8a, anxiety 8a, and PASS-20 in individuals with chronic low back pain.

Introduction: Depression and anxiety are the most commonly reported mental health conditions. The Patient-Reported Outcomes Measurement Information System Short Form v1.0-Depression 8a (PROMIS-D-8a), Anxiety 8a (PROMIS-Anx8a), and Pain Anxiety Symptoms Scale-20 (PASS-20) measures were designed to assess depression, general anxiety, and pain-related anxiety, respectively. Objectives: To examine the responsiveness and estimate the clinically important differences (CIDs) of the Thai version of these measures in individuals with chronic low back pain (CLBP). Methods: The study sample comprised 144 participants with CLBP. Responsiveness was evaluated by calculating the change scores, effect sizes (ESs), standardized response means (SRMs), area under the curve (AUC), and correlations between the change scores and associated Global Perceived Effect (GPE). We also estimated CIDs by the difference in mean change score between improved and unchanged groups and standard error of measurement (SEM) for each measure. Results: Statistically significant differences in the mean change scores, ESs, and SRMs supported the responsiveness of all measures. The AUCs achieved acceptable discriminatory ability (0.71-0.72) for moderate improvement but not for any improvement (0.65-0.68). The correlations between GPE and change scores on all measures were low (r ranging 0.28-0.33). The estimated CIDs for the PROMIS-D-8a, PROMIS-Anx8a, and PASS-20 were 3.64, 4.20, and 8.80, respectively. Conclusion: The PROMIS-D-8a, PROMIS-Anx8a, and PASS-20 measures were sensitive for detecting clinical changes over time in individuals with CLBP. The CID values can be used as reference points for assessing meaningful improvements in the domains assessed by these scales in clinical and research practice.

McKenzie neck exercise versus cranio-cervical flexion exercise on strength and endurance of deep neck flexor muscles, pain, disability, and craniovertebral angle in individuals with chronic neck pain: a randomized clinical trial.

PURPOSE: To compare the effectiveness of McKenzie neck exercise and cranio-cervical flexion (CCF) exercise on strength and endurance of deep neck flexor (DNF) muscles, pain, disability, and craniovertebral angle (CVA) in individuals with chronic neck pain. METHODS: Forty individuals with chronic neck pain were randomly allocated to the McKenzie neck or CCF exercise group. Each group performed exercises at home daily. The strength and endurance of DNF muscles were measured at baseline, immediately after the first exercise session, and each week follow-up for six weeks. Average pain over the past week was measured at baseline and each week follow-up for six weeks. Disability and CVA were measured at baseline and the end of six weeks. RESULTS: At six weeks, both groups exhibited significant improvements across all outcome variables (p < 0.001) but there were no differences between groups (p > 0.05). The significant difference from baseline in the strength of DNF muscles was observed as early as the second week of each intervention (p ≤ 0.001). The significant difference from baseline in the endurance of DNF muscles was observed as early as the first week in the CCF exercise group (p < 0.05) and the second week in the McKenzie neck exercise group (p < 0.05). A significant decrease in pain intensity from baseline was observed after the first week in the McKenzie neck exercise group (p < 0.001) while it was after the second week in the CCF exercise group (p < 0.05). CONCLUSION: Both the McKenzie neck exercise and CCF exercise produced similar effects in enhancing the strength and endurance of the DNF muscles, decreasing pain, alleviating neck disability, and improving the CVA.

Cross-cultural adaptation and psychometric properties of the Thai version of the patient-reported outcomes measurement information system short form- depression 8a in individuals with chronic low back pain.

BACKGROUND: The study aimed to cross-culturally adapt the Patient-Reported Outcomes Measurement Information System Short Form v1.0 - Depression 8a (PROMIS SF v1.0 - Depression 8a) into Thai and evaluate its psychometric properties in individuals with chronic low back pain (CLBP). METHODS: The PROMIS SF v1.0- Depression 8a was translated and cross-culturally adapted into Thai using the Functional Assessment of Chronic Illness Therapy translation methodology. Two hundred and sixty-nine individuals with CLBP completed the Thai version of PROMIS SF v1.0- Depression 8a (T-PROMIS-D-8a) scale and a set of measures assessing validity criterion domains. Structural validity, internal consistency, and test-retest reliability at a 7-day interval of the T-PROMIS-D-8a scale were computed and its construct validity was evaluated by computing correlations with the Thai version of Patient Health Questionnaire-9 (T-PHQ-9), Numeric Rating Scale of pain intensity (T-NRS), and Fear Avoidance Beliefs Questionnaire (T-FABQ). RESULTS: Data from 269 participants were analyzed. Most participants were women (70%), and the sample had a mean age of 42.5 (SD 16.6) years. The findings supported the unidimensionality, internal consistency (Cronbach's alpha = 0.94), and test-retest reliability (ICC [2,1] = 0.86) of the T-PROMIS-D-8a. A floor effect was observed for 16% of the sample. Associations with the T-PHQ-9, T-NRS, and T-FABQ supported the construct validity of the T-PROMIS-D-8a. CONCLUSIONS: The T-PROMIS-D-8a was successfully translated and culturally adapted. The findings indicated that the scale is reliable and valid for assessing depression in Thai individuals with CLBP.

Gluteus medius muscle strengthening exercise effects on medial longitudinal arch height in individuals with flexible flatfoot: a randomized controlled trial.

This study aimed to compare the effects of 8 weeks of foot plus hip exercise to foot exercise alone on medial longitudinal arch (MLA) parameters; navicular drop (ND), arch height index (AHI), plantar pressure, static balance, and dynamic balance were measured at baseline, 4 weeks, and 8 weeks. A total of 52 healthy participants with bilateral flatfoot were randomly assigned into foot exercise (n=26) and foot plus hip exercise (n=26) group. At 4 weeks, the foot plus hip exercise group showed significantly less ND (P=0.002), plantar pressure at the medial forefoot (P=0.002), and mediolateral displacement (P=0.001) while showing a greater AHI (P=0.019) than the foot exercise group. At 8 weeks, there was also significantly less plantar pressure at the medial hindfoot (P=0.017) and less anteroposterior displacement (P=0.002) in the foot plus hip exercise group than in the foot exercise group. No significant differences between groups were found in dynamic balance. The addition of gluteus medius muscle strengthening exercise to foot exercise was more effective in supporting the MLA than performing foot exercise alone.

Effects of active scapular correction on cervical range of motion, pain, and pressure pain threshold in patients with chronic neck pain and depressed scapula: a randomized controlled trial.

BACKGROUND: Correction of scapular alignment is advocated as a component for alleviating symptoms for patients with neck pain. OBJECTIVE: The study aimed to examine the effect of active scapular correction on cervical range of motion (ROM), pain, and pressure pain threshold (PPT) in patients with chronic neck pain with depressed scapula. METHODS: A randomized control trial research design was conducted. Twenty-eight participants with chronic neck pain and depressed scapula were randomly assigned to either the intervention (n = 14) or control (n = 14) group. Active cervical rotation ROM, pain at maximum cervical rotation, and PPT over the upper trapezius muscle region were measured at baseline and post active scapular correction. RESULTS: The participants in the intervention group showed significantly greater active cervical rotation ROM and less pain at maximum cervical rotation than the control group, both on the ipsilateral (p < 0.01) and contralateral (p < 0.05) sides of the depressed scapula. No significant difference in PPT between the groups was demonstrated (p = 0.194). CONCLUSION: Active scapular correction intervention resulted in an immediate increase in active cervical rotation ROM and a decrease in neck pain at maximum cervical rotation.

Responsiveness of the UW Concerns About Pain Scale and UW Pain-Related Self-Efficacy Scale in Individuals With Chronic Low Back Pain.

OBJECTIVES: The aim was to examine the responsiveness, presence of floor or ceiling effects, and minimal clinically important differences (MCIDs) for 2 new measures of pain-related catastrophizing and self-efficacy in individuals with chronic low back pain. METHODS: A total of 183 individuals with chronic low back pain recruited from physical therapy clinics in Thailand completed the Thai versions of the 6-item University of Washington Concerns About Pain scale (T-UW-CAP6) and 6-item University of Washington Pain-Related Self-Efficacy scale (T-UW-PRSE6) at baseline and at 4 weeks follow-up. Perceived change in low back symptom was assessed at 4 weeks using a 7-point measure of Global Perceived Effect (GPE). Responsiveness of the T-UW-CAP6 and the T-UW-PRSE6 scale scores were evaluated by computing the effect sizes and standardized response means for change over time, and examining these as a function of the GPE ratings. Floor and ceiling effects were examined by evaluating the score distributions. Scale core MCIDs were estimated by computing a half a SD and SE of measurement statistics for each scale. RESULTS: Responsiveness of the scales to pain treatment was supported by differences found in the mean change scores as a function of the treatment response categories. No significant floor or ceiling effects were found for either measure. Changes of 4.38 and 3.68 appeared to be the smallest change score perceived as clinical meaningful for the T-UW-CAP6 and T-UW-PRSE 6 scale scores, respectively. DISCUSSION: The T-UW-CAP6 and T-UW-PRSE6 demonstrated good ability to detect perceived changes over time in patients with chronic low back pain. The MCIDs values provide a benchmark for assessing individual improvement in this clinical context.

Immediate and short-term effects of kinesiotaping and lower extremity stretching on pain and disability in individuals with plantar fasciitis: a pilot randomized, controlled trial.

BACKGROUND: Plantar fasciitis (PF) can disturb individual's weight-bearing activities. Hence, conservative treatments with immediate effect in reducing pain and improving foot function is required. OBJECTIVE: This study compared the effect of kinesiotaping and stretching exercise in individuals with PF. METHODS: Thirty patients with PF were randomly divided into three groups, and received kinesiotaping, stretching exercise, and a combination of the two aforementioned interventions. Pain intensity and foot disability were measured at baseline, immediately after the first treatment, and at one week. RESULTS: Immediately after the first treatment, all groups showed significant changes in heel pain intensity (p ≤ .012) with the standardized response mean (SRM) of 2.85, 1.96, and 1.43 for the taping, stretching, and the combination groups, respectively. Nevertheless, no significant change in foot disability was found (p > .05). At the one week, all groups continued to demonstrate significant reduction in heel pain (p ≤ .012) with the SRM of 1.78, 2.84, and 2.09 for the taping, stretching, and the combination groups, respectively. While the combination group showed significant reduction in foot disability (p = .024). However, there was no significant difference of the change score in all parameters among the three groups (p > .05). CONCLUSION: Improvement in heel pain was observed in all groups after the first treatment. However, improvement in foot function over one week was observed only among those who received the combined treatment. Further studies on larger samples are required to establish the superiority of the combined treatment over kinesiotaping or stretching alone.

Responsiveness of the PROMIS-29 Scales in Individuals With Chronic Low Back Pain.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To evaluate responsiveness and estimate the minimal clinically important differences (MCIDs) for the Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) scales in individuals with chronic low back pain. SUMMARY OF BACKGROUND DATA: The PROMIS-29 questionnaire assesses seven health-related quality-of-life domains. However, research to evaluate the responsiveness and MCIDs of the PROMS-29 scores in individuals with low back pain is limited. METHODS: The study was conducted in physical therapy clinics in Thailand, using validated Thai versions of the study measures. One hundred and eighty-three individuals with chronic low back pain completed the PROMIS-29 at baseline and at 4-weeks follow-up. Perceived change in each domain assessed by the PROMIS-29 scales was assessed at 4 weeks using a 7-point measure of Global Perceived Effect (GPE). Responsiveness of the PROMIS-29 scale scores was evaluated by examining the effect sizes, the standardized response means (SRMs) for change over time, and examining these as a function of the GPE ratings. MCIDs for the scales were estimated by computing a half a standard deviation (SD) and standard error of measurement statistic for each scale. RESULTS: The mean change scores, effect sizes, and SRMs increased as a function of the GPE ratings. Significant differences in change scores between those who reported that they were very much improved and those who did not improve were found for the PROMIS-29 Pain Intensity, Physical Function, and Anxiety scales. The correlations between changes scores and GPE ratings were mostly weak in magnitude. The MCID estimates computed as 0.50 of a SD unit and as a standard error of measurement showed similar values. CONCLUSION: The PROMIS-29 scale scores assessing pain intensity, physical function, and anxiety evidenced the most responsivity in the study sample. The results, when considered in light of the findings from other investigators, support 5.0 points as a reasonable MCID for most of the PROMIS-29 scales. Further studies are needed to determine the generalizability of the findings.Level of Evidence: 2.

Cross-cultural adaptation, reliability, and construct validity of the Thai version of the Patient-Reported Outcomes Measurement Information System-29 in individuals with chronic low back pain.

PURPOSE: To culturally adapt the Patient-Reported Outcomes Measurement Information System-29 into Thai (T-PROMIS-29) and evaluate the reliability and validity of the culturally adapted questionnaire. METHODS: The translation was performed using the Functional Assessment of Chronic Illness Therapy (FACIT) translation guidelines. Unidimensionality, internal consistency, and test-retest reliability at a 1-week interval for the translated measure were computed. Construct validity was evaluated by computing correlations between the T-PROMIS-29 scores and selected SF-36 scale scores. RESULTS: The study sample comprised of 241 participants with chronic low back pain. Internal consistencies were good to excellent, with Cronbach's alphas ranging from 0.84 to 0.94. The test-retest stability of all T-PROMIS-29 domains were moderate to good, with ICCs(2,1) ranging from 0.57 to 0.74. Unidimensionality, convergent validity, and divergent construct validity were satisfactory. CONCLUSIONS: The findings support the reliability and validity of the T-PROMIS-29 scale scores. The measure can be used to assess key quality of life domains in individuals from Thailand with chronic low back pain.

Cross-cultural adaptation, test-retest reliability, and construct validity of the Thai version of the University of Washington Pain-Related Self-Efficacy Scale.

INTRODUCTION: One psychosocial factor in the biopsychosocial model is pain-related self-efficacy, which has been shown to be a strong predictor of response to pain treatment. OBJECTIVES: To cross-culturally adapt the University of Washington Pain-Related Self-Efficacy Scale (UW-PRSE6) into Thai and evaluate its psychometric properties. METHODS: The study was approved by the Chulalongkorn University Human Ethics Committee (COA No. 156/2018). The original UW-PRSE6 was cross-culturally adapted using the Functional Assessment of Chronic Illness Therapy translation methodology. Two hundred forty-one individuals with chronic low back pain completed the Thai version of UW-PRSE6 (T-UW-PRSE6), Thai Fear Avoidance Beliefs Questionnaire (T-FABQ), and Thai Medical Outcome Study Short-Form 36 (T-SF-36). A subset of 152 participants completed the T-UW-PRSE6 again after a 7-day interval. Cronbach's alpha and intraclass correlation coefficients were calculated to estimate internal consistency and test-retest reliability, respectively. The construct validity of the T-UW-PRSE6 was evaluated by computing Spearman correlation coefficients between the T-UW-PRSE6 score and the measures of the validity criterion variables. RESULTS: The T-UW-PRSE6 had good internal consistency (Cronbach's alpha = 0.85) and moderate test-retest reliability (intraclass correlation coefficient [2,1] = 0.72). The T-UW-PRSE6 was negatively correlated with the T-FABQ Work and Physical Activity subscales (rs = -0.34 and -0.34, respectively) and positively correlated with the General Health, Physical Functioning, Role Physical, Role Emotional, Social Functioning, Bodily Pain, Vitality, and Mental Health scales of the T-SF-36 (rs = 0.38, 0.42, 0.54, 0.51, 0.47, 0.54, 0.41, and 0.40, respectively). CONCLUSION: The T-UW-PRSE6 demonstrated acceptable psychometric properties for assessing pain-related self-efficacy in individuals with chronic low back pain, making available a measure for facilitating future cross-cultural research on pain self-efficacy.

Predictors for Nonspecific Low Back Pain in Rubber Farmers: A 1-Year Prospective Cohort Study.

High prevalence of low back pain (LBP) has been reported among farmers. A number of contributing factors have been associated with LBP. However, predictors for LBP in this population are unknown. This longitudinally designed study aimed to identify the predictors of LBP in a sample of rubber farmers whose work involves heavy manual labor. Three hundred and twenty-seven rubber farmers, aged 18 to 70 years who reported no LBP in the previous year, were face-to-face interviewed and examined physically. The incidence of LBP was assessed monthly. The 12-month incidence of LBP in the cohort was 35%. Having a history of LBP (hazard ratio = 1.55, 95% confidence interval = 1.05-2.30) and an active job (hazard ratio = 1.98, 95% confidence interval = 1.16-3.40) were the predictors for the new onset of LBP in this sample. These 2 factors could therefore potentially be targeted to prevent or reduce the incidence of LBP in rubber farmers.

Effectiveness of the Simultaneous Stretching of the Achilles Tendon and Plantar Fascia in Individuals With Plantar Fasciitis.

BACKGROUND: Since the plantar fascia and the Achilles tendon are anatomically connected, it is plausible that stretching of both structures simultaneously will result in a better outcome for plantar fasciitis. METHODS: Fifty participants aged 40 to 60 years with a history of plantar fasciitis greater than 1 month were recruited. They were prospectively randomized into 2 groups. Group 1 was instructed to stretch the Achilles tendon while group 2 simultaneously stretched the Achilles tendon and plantar fascia. RESULTS: After 4 weeks of both stretching protocols, participants in group 2 demonstrated a significantly greater pressure pain threshold than participants in group 1 ( P = .040) with post hoc analysis. No significant differences between groups were demonstrated in other variables ( P > .05). Concerning within-group comparisons, both interventions resulted in significant reductions in pain at first step in the morning and average pain at the medial plantar calcaneal region over the past 24 hours, while there were increases in the pressure pain threshold, visual analog scale-foot and ankle score, and range of motion in ankle dorsiflexion ( P < .001). More participants in group 2 described their symptoms as being much improved to being completely improved than those in group 1. CONCLUSION: The simultaneous stretching of the Achilles tendon and plantar fascia for 4 weeks was a more effective intervention for plantar fasciitis. Patients who reported complete relief from symptoms at the end of the 4-week intervention in the simultaneous stretching group (n = 14; 56%) were double that of the stretching of the Achilles tendon-only group (n = 7; 28%). LEVEL OF EVIDENCE: II, lesser quality RCT or prospective comparative study.

The prevalence of low back pain and its associated factors in Thai rubber farmers.

OBJECTIVES: Low back pain (LBP) is one of the most prevalent musculoskeletal disorders in the general population, especially among manual laborers. Moreover, it often brings about lost wages and additional medical expenses. However, the potential risk factors for LBP are unknown. This study aimed to estimate the prevalence of LBP and to determine the individual, occupational, and psychosocial factors associated with LBP among rubber farmers. METHODS: A cross-sectional survey was conducted among 450 Thai rubber farmers using cluster random sampling. Data were collected using face-to-face interviews and objective examination and were analyzed using multivariate logistic regression. RESULTS: Of the 433 rubber farmers, the point and 12-month prevalence of LBP in rubber farmers was 33% and 55.7%, respectively. BMI, primary school education, exposure to pesticides, and tapping below knee level were statistically associated with LBP after controlling for other variables. CONCLUSIONS: Low back pain is common among rubber farmers. Only four factors were identified as being associated with the high prevalence of LBP. However, these factors might be altered if more variables are taken into account. Further research investigating the causal relation between these factors and LBP should be conducted.

Changes in sitting posture affect shoulder range of motion.

OBJECTIVE: To assess the effect of slouched sitting on shoulder range of motion (ROM). METHOD: 30 asymptomatic males aged between 18 and 35 years with no history of shoulder problems within the last 6 months. Shoulder ROMs in flexion and abduction as well as external rotation and internal rotation in 90° of shoulder abduction were measured while the subjects sat in 3 different sitting postures. RESULTS: There were statistically significant mean differences among the 3 sitting postures regarding thoracic kyphosis and shoulder ROMs (p < 0.001). Post hoc analyzes demonstrated significant differences in all comparisons (p < 0.001). CONCLUSION: Changes in sitting posture affect shoulder ROMs in all directions tested. Greater changes in shoulder ROMs were associated with greater increase in thoracic kyphosis. These findings suggest that even subtle changes in thoracic kyphosis need to be considered during shoulder evaluation.

Immediate effects of the central posteroanterior mobilization technique on pain and range of motion in patients with mechanical neck pain.

PURPOSE: To determine the immediate effects of the central posteroanterior (PA) mobilization technique on both pain and active cervical range of motion in patients with mechanical neck pain presenting with central or bilateral symptoms. METHODS: A randomized controlled trial was conducted in 60 patients who were randomly allocated into either 'central PA' or 'random' mobilization group. Two physical therapists and one assessor participated. Outcome measures included neck pain at rest, pain on the most painful movement, and active cervical range of motion taken before and immediately 5 min after the mobilization treatment. RESULTS: Significant reductions in pain at rest and on the most painful movement were noted within-group comparisons (p < 0.001). However, the 'central PA' mobilization group obtained a significantly greater reduction in pain on the most painful movement than the 'random' mobilization group (p < 0.05). Both mobilization techniques had no effects on the active cervical range of motion. However, the differences in the means of pain reduction between both mobilization techniques were modest (<10 mm). CONCLUSION: The clinical recommendation regarding the selection of the central PA mobilization technique for treating patients with central or bilateral mechanical neck pain is therefore arguably.

Abdominal muscle activity during abdominal hollowing in four starting positions.

The aim of this study was to investigate the activity of the rectus abdominis (RA), external abdominal oblique (EO), and transversus abdominis/internal abdominal oblique (TrA/IO) muscles during abdominal hollowing (AH) in four positions: crook lying, prone lying, four-point kneeling, and wall support standing. Thirty-two healthy participants, aged 21.3+/-0.8 years were recruited. They were instructed to perform maximal voluntary contraction (MVC) and AH. The electromyography (EMG) data of each muscle during AH were normalized as a percentage of MVC. During AH in all four starting positions, significant differences were found in the EMG activity of RA, EO, and TrA/IO (p<0.001). The TrA/IO exhibited the highest while the RA exhibited the lowest EMG activity. Among the four different starting positions, only the TrA/IO showed significant difference in mean EMG activity (p<0.001). The results suggest that all four starting positions can facilitate TrA/IO activity with minimal activity from RA and EO.

The immediate effects of mobilization technique on pain and range of motion in patients presenting with unilateral neck pain: a randomized controlled trial.

OBJECTIVE: To determine the immediate effects on both pain and active range of motion (ROM) of the unilateral posteroanterior (PA) mobilization technique on the painful side in mechanical neck pain patients presenting with unilateral symptoms. DESIGN: Triple-blind, randomized controlled trial. SETTING: Outpatient physical therapy, institutional clinic. PARTICIPANTS: Patients (N=60), 2 physical therapists, and 1 assessor involved in this study. INTERVENTIONS: The patients were randomly allocated into either preferred or random mobilization group by using an opaque concealed envelope. The first therapist performed the screening, assessing, prescribing the spinal level(s), and the grade of mobilization. The second therapist performed the mobilization treatment according to their allocated group stated in an envelope. The assessor who was blind to the group allocation conducted the measurements of pain and active cervical ROM. MAIN OUTCOME MEASURES: Pain intensity, active cervical ROM, and global perceived effect were measured at baseline and 5 minutes posttreatment. RESULTS: After mobilization, there were no apparent differences in pain and active cervical ROM between groups. However, within-group changes showed significant decreases in neck pain at rest and pain on most painful movement (P<0.001) with a significant increase in active cervical ROM after mobilization on most painful movement (P=0.002). CONCLUSIONS: The results of this study did not provide support for the preference of the unilateral PA mobilization on the painful side to the random mobilization.

Comparison of skin surface temperature during the application of various cryotherapy modalities.

OBJECTIVE: To compare the skin surface temperature during the application of 4 cryotherapy modalities. DESIGN: A repeated-measures design. SETTING: Laboratory experiment. PARTICIPANTS: Convenience sample of 50 women (age range, 20-23 y; mean, 20.6+/-0.8 y). INTERVENTIONS: Each of the 4 cryotherapy modalities (ice pack, gel pack, frozen peas, mixture of water and alcohol) was applied randomly to the skin overlying the right quadriceps femoris muscle. MAIN OUTCOME MEASURE: Skin surface temperature recorded every minute for 20 minutes. RESULTS Throughout 20 minutes of cryotherapy application, the ice pack and mixture of water and alcohol showed significantly lower skin surface temperatures than the gel pack or frozen peas (P < .001). The mean skin surface temperature at the 20th minute of application with the ice pack, gel pack, frozen peas, and mixture of water and alcohol was 10.2 degrees +/-3.5 degrees , 13.9 degrees +/-4.1 degrees , 14.4 degrees +/-3.0 degrees , and 10.0 degrees +/-4.5 degrees C, respectively. CONCLUSIONS: The ice pack and mixture of water and alcohol were significantly more efficient in reducing skin surface temperature than the gel pack and frozen peas.