***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Therapeutic trials often attempt to “ blind ” patient and investigator to the true nature of treatments received , reducing the influences of conscious or subconscious prejudices . In drug trials , this is accomplished with placebo tablets , but blinding in trials of physical treatments is more problematic . This issue arose in a clinical trial of transcutaneous electrical nerve stimulation ( TENS ) for patients with chronic low back pain . Several study design features were incorporated to promote blinding : use of sham TENS units visually identical with real units , exclusion of potential subjects with previous TENS experience , avoidance of a crossover design and use of identical visit frequency , instructions and modifications in electrode placement . Subjects were asked not to discuss treatments with the clinicians who performed outcome assessment s. Both patients and clinicians were asked to guess actual treatment assignments at the trial 's end . Every patient in the true TENS group believed the unit was functioning properly , but the degree of certainty varied . In the sham TENS group , 84 % also believed they had functioning units , but their certainty was significantly less than in the active treatment group . Differences in patient perceptions did not affect compliance , as the two groups had similar dropout rates , appointment compliance , days of TENS use and daily duration of TENS use . Clinicians guessed treatments correctly 61 % of the time ( as opposed to 50 % expected by chance ) , again suggesting partial success in blinding . These efforts at blinding may partly explain the negative trial results for TENS efficacy . We conclude that complete blinding is difficult to achieve because of sensory difference in treatment and unintended communication between patient and examiner . Nonetheless , trials of physical treatments can achieve partial blinding with the techniques described here , and the success of blinding can be assessed with simple questions at study completion The effect of active h and exercise and warm wax treatment was evaluated in 52 rheumatoid arthritis patients r and omized into four groups : ( 1 ) both exercise and wax bath , ( 2 ) exercise only , ( 3 ) wax bath only , and ( 4 ) controls .  Treatment was given three times a week for 4 weeks . Deficits in flexion and extension in digits II-V bilaterally , grip function , grip strength , pain , and stiffness were measured before and after the treatment period . The control group was measured at corresponding times . Wax bath treatment followed by active h and exercise result ed in significant improvements of range of motion ( ROM ) and grip function . Active h and exercise alone reduced stiffness and pain with nonresisted motion and increased ROM .  Wax bath alone had no significant effect OBJECTIVE To evaluate the effects of local application of ice chips , ligno-paraffin , short-wave diathermy , and nitrogen-cold air on skin and intraarticular temperature . METHODS Forty-two healthy subjects were divided into 4 treatment groups . A temperature probe was inserted into the knee joint cavity and another placed on the overlying skin , and changes in temperature over 3 hours , by treatment group , were recorded . RESULTS The mean skin surface temperature dropped from 27.9 degrees C to 11.5 degrees C after application of ice chips , and from 28.8 degrees C to 13.8 degrees C after application of cold air . The mean intraarticular temperature decreased from 31.9 degrees C to 22.5 degrees C and from 32.9 degrees C to 28.8 degrees C , respectively , after these 2 treatments . Shortwave diathermy  increased skin temperature by 2.4 degrees C ; intraarticular temperature was increased only 1.4 degrees C by short-wave diathermy . Treatment with ligno-paraffin increased the skin surface temperature 8.9 degrees C ; the temperature in the joint cavity was increased 3.5 degrees C. CONCLUSION The use of short-wave diathermy and superficial heat packs in the treatment of patients with arthritis may potentially cause harm by increasing intraarticular temperature . This may have major implication s regarding treatment policy for patients with arthritis OBJECTIVE To evaluate and compare the effects of locally applied heat and cold treatments on skin and intraarticular temperature in patients with arthritis . METHODS Thirty-nine patients with arthritis of the knee were divided at r and om into 4 treatment groups ( ice chips , nitrogen cold air , ligno-paraffin , and placebo short wave ) . A temperature probe was inserted into the knee joint cavity and another placed on the overlying skin , and changes in temperature over 3 hours were recorded for each treatment group . RESULTS The mean temperature of the surface of the skin dropped from 32.2 degrees C to 16.0 degrees C after application of ice chips and from 32.6 degrees C to 9.8 degrees C after application of nitrogen cold air ; the mean intraarticular temperature decreased from 35.5 degrees C to 29.1 degrees C and from 35.8 degrees C to 32.5 degrees C , respectively , after these treatments . Treatment with ligno-paraffin increased the surface temperature by 7.5 degrees C and the temperature in the joint cavity by 1.7 degrees C. No significant changes were observed with placebo short wave diathermy . CONCLUSION The traditional model , that intraarticular temperature is decreased by superficial heat and increased by superficial cold , must be discarded . In arthritis patients , intraarticular temperature is increased by superficial heat and decreased by superficial cold . This has clear consequences for treatment policy Ninety consecutive patients undergoing primary knee arthroplasty received local cryotherapy 72 hours after surgery for pain relief . Thermal-pad circulating temperatures were r and omly assigned to 50 degrees , 60 degrees , or 70 degrees F ( room temperature ) . Pain relief was monitored using patient-controlled analgesia machines . The amount of morphine received and number of attempts per hour were statistically analyzed with relation to temperature group , age , sex , weight , side , and diagnosis . The amount of morphine injected was positively correlated to the number of attempts per hour and moderately correlated to body weight . There was no correlation between thermal-pad temperature or any other parameter and the amount of morphine injected after surgery Superficial heat and cold are commonly used therapeutic methods in patients with rheumatoid arthritis . Both procedures have analgesic effect . In 30 in patients with rheumatoid arthritis the pain threshold was measured before and after warm bath and ice massage .  Rheumatoid patients had significantly lower pain threshold compared to the healthy subjects in normal circumstances . Heat and cold remarkably raise the pain threshold right after the application . The pain threshold is also raised 10 and 30 min after cryotherapy , but not after the warm bath . Between investigated groups there were no statistically significant differences in the pain threshold values in any observed time . We consider that both methods have a reasonable place in the therapy of rheumatoid arthritis 
    Output:
    
There was no effect on objective measures of disease activity ( including inflammation , pain and x-ray measured joint destruction ) of either ice versus control or heat versus control .
There was no difference in patient preference for heat  or ice .
No harmful effects of ice or heat  were reported .
REVIEW ER 'S CONCLUSIONS Since patients enjoy thermotherapy , and there are no harmful effects , thermotherapy should be recommended as a therapy which can be applied at home as needed to relieve pain .
There is no need for further research on the effects of heat or cold for RA