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Icing and Injuries

I am asked weekly about how to treat injuries when it comes to heat vs cold. This post will be about ice and highlighting the differences between ice baths vs icing injuries. I will work on the benefits of heat later because that's another common question. Let's start with the beginning to find out why people still say ice for injuries.

The phrase RICE was coined when Dr. Gabe Mirkin published his book in 1978. The earliest published article for icing tissues can be found in the 1940’s. Surgeons slowed down the metabolism during amputations to preserve more tissue. Also, pain control, death rates during operations and reduce infections. RICE was based on the best practice and evidence at the time. Rest, Ice, Compression and Elevation were considered the best algorithm for treating acute injuries. Since then the research has changed how to treat injuries regardless if it’s acute, sub-acute or chronic. In 2013 Dr. Mirkin changed his position based on the new evidence, which shows that ice slows down metabolic processes and healing. The goal is to get through the inflammatory reaction faster to promote healing. The important message here is that the person who created RICE said to stop doing it 9 years ago.  Kudos to Dr. Mirkin as I have not met many people who will change a view or opinion. Not very many people I have met will change a view or opinion.  

The acronym has changed over the years as well. It evolved to PRICE, MICE, METH, MEAT and PEACE AND LOVE. The acronyms are unforgettable now. Protection, Rest, Ice, Compression and Elevation.  Movement, Elevation, Traction and Heat or Movement, Elevation, Analgesics and Traction. Protect, Elevate, Avoid anti-inflammatories, Compress, Educate, Load, Optimism, Vascularization and Exercise. Which one is the best? It depends on the severity of the injury, what the evaluation showed, injury history and goals of the patient. Prescription or over the counter anti-inflammatory medications could be needed for controlling the pain. These can slow down tissue repair so taking this into consideration is needed and could increase time. Most tears, sprains and strains are controlled by NSAIDS. Severe swelling and pain might need a dose pack. These are prescription anti-inflammatories that start out with a high dose (usually 7 pills) then reduce over the week. 

However, patients often tell me they are icing injuries. I saw a basketball player holding 2 large bags of ice on his knees during a game and this was NBA level. I admit it is difficult to stay up to date on research and constantly change how injuries are managed. Often it comes back in circles but it is a necessary process for the manual therapy world. As for the benefit of ice placed directly on an injured tissue, It helps by making it numb. In school we were taught the 4 stages of ice: Cold, burning, pain and numbness. That is why people say ice helps, they make it numb. The argument for an ice bath is different and designed to help recovery, not a bag of ice on the injured area.

Getting to what ice does to injured tissues: It suppresses the immune systems response which slows the recovery process. Inflammation and swelling are not bad, this has to occur in order for injuries to heal. There are three phases of the inflammatory response: Inflammatory, repair and remodel. After an injury the cells send out a signal that they have been damaged. These are called cytokines and they allow the small blood vessels around the area to dilate. The dilation allows enough room for white blood cells to enter into the damaged area. Particularly, a white blood cell called a macrophage shows up and starts eating cell debris pac-man style. Insulin-like growth factor eventually arrives and this moves to the next phase. Growth factors are released as well which continues until the tissues are healed. (for the record, I just did a really brief description of the inflammatory reaction, you biology majors take a breath) It is worth noting that chronic inflammation is bad and leads to chronic disease which is not what is being described currently. 

Why is heat better than ice for an acute injury? It brings blood flow into the area, turbo charging the pathway for the cells to work faster. Getting through the phases faster is the goal, not slowing it down by adding ice. The less blood into the area, the slower the process. Adding movement also promotes circulation and stimulates recovery. Injured tissues respond to the load of exercise/rehabilitation.  This helps the tissues to heal faster. Elevation helps manage swelling, above the level of the heart is the standard for controlling swelling. Compression socks or other garments are other great options. Traction helps provide space in tissues in order for cellular debris and nutrients to be exchanged and makes it easier to promote healing. 

What are my thoughts for getting through an injury faster?

Get the injury evaluated by a clinician. I prefer a provider with a sports medicine background and is physically active. Unless you have been injured or are active, it can be difficult understanding an athlete's mentality.  Avoid Webmd diagnosis. I love when patients read and ask questions but it’s most likely not cancer. Use NSAIDS for a short period of time to control the pain. Yes, it will affect healing if used long term. Compression, elevation, traction and heat are all options that can be done together. Taping can also be a great addition of support. Graston technique or any other type of myofascial work is beneficial to improve healing and control scar tissue. Rehabilitation is a must to resolve the injury from returning, oftentimes the pain starts to reduce which gives the illusion it is 100%. This is where flare ups happen and prolong recovery. My favorite is dry needling with electrical stimulation. This helps with pain control, improves circulation and healing time.There is extensive research to validate this therapy and it is worth it.

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