My Protocol for Plantar Pain and Heel PainMY UNDERSTANDING OF PLANTAR PAIN AND ITS PATHOPHYSIOLOGYThere are four causes will causing heel pain: (1) Inflammation of fatty pad. (2) Strained tendon and Tendonitis. (3) Osteological spurs. (4) Bursitis. For each of the above problems I have a similar protocol however for each of the above problems the there can be varied degrees of response to this treatment. The reason I have the same protocol is I do not address any of those problems directly I go for the main cause. The main cause to me is what is stopping the body from resolving the above four problems. In my opinion the main cause is muscle pain and tightness which blocks the body from being able to heal itself of these four problems. All of these four areas get very little direct circulation. If the trickle of vascular support to these areas is compromised in the slightest it results in the wear and tear of daily walking and standing becoming injurious. The body when resting at night cannot keep up to the strain of the day. If you however are able to increase the circulation to these areas even for a short time you can make up for years of wear and tear. It took years to create the problem but a massive increase in blood and nutrients to an area and a continued good circulation can work miracles or what seems like anyway. In my approach I address specifically the circulation and muscles. A tight muscle will not allow for a free flow of blood and fluids through or around it. However, once the area is supple and relaxed then lymphatic drainage and blood oxygenation and nutrients can flow to help an area renew itself. This will result in a reduction in pain as well as inflammation. The area will feel stronger and all connected areas will also feel better. The body knows how to heal humans have had these problems since the beginning and a human that cannot walk does not eat. So with this simple logic let us trust aid the body circulation and it will fix its own problems we still cannot fathom the amazing healing abilities of our bodies. MY TREATMENT TECHNIQUE In the initial treatment of Plantar Pain I use gentle approach with TCM acupunture protocol along with electro stimulation. This usually uses balancing points like P7 on the wrist or other ashi or tender points around the wrist or elbow area. Also ear seeds on the heel area of the ear are also used. The electrostimulation is usually in the local area of pain or up in the calf area on motor points relating to the muscles that connect to the achilles or plantar ligaments and tendons. This is usually followed by a mild massage with instructions to soak the feet in a detox bath. The self massage is shown to be most important and it should be painful to a point to get results. The theory is that if there is pain there is a blockage to remove the blockage acupuncture is used around the wrist. This tells the body to adjust the circulation around the heel and foot. When the circulation increases then healing occurs and the body starts to catch up on the viscous circle of inflammation and pain. The ear points have been found to influence the brain and how it interprets pain as well as change circulation patterns in various areas in the body to aid healing in areas of chronic inflammation and pain. This first protocol is not always effective but it is gentle and comfortable for the client and along with other interventions have been found to be very effective. Should the client be comfortable with trigger point therapy and has been using a ball to massage the feet calf and gluteal areas and still has not found adequate relief then more direct approaches are used. Dry needling or wet needling with procaine 1% and Hydroxal Cobalamin (B12) in a 2cc/1cc repsective syringe. This protocol can sometimes be used earlier if the client is interested and understands the medical theory behind trigger point injection. Also it is generally more effective to use trigger point injection and will lead to a faster recovery. If time is an issue then the added risk and expense with some discomfort can be a factor to move to trigger point injection before the above TCM procedure. If there are allergy issues then a dry needle approach would be used however the wet needle is generally more comfortable due to the procaine also there is a more lasting effect on the muscles as a result. The main muscles to be needled are the Soleus, Quadratus Plantae, The Flexor Digitorum Brevis, and ABd Hallucis depending on tenderness on palpation. Other muscles assessed for tenderness due to thier supporting function will be Gastroc, Flexor Digitorum Longus, Flexor Hallucis Longus, peroneus longus; peroneus brevis); tibialis anterior; extensor hallucis longus; extensor digitorum longus Loading muscles like gluteus maximus; gluteus medius and gluteus minimus are almost always included since they are major drivers so to speak for the lower body. These major muscles are large in size and will effect the whole body if they are tight or problematic with trigger points. When needling the gluteal area I usually clear the whole area and it does not take very long and is one of the safest and most comfortable area to have needled in this way. Other lesser loading muscles can be the piriformis, tensor fascia latae on the side of the leg; adductor longus; adductor magnus; adductor brevis, semitendinosis; semimembranosis and biceps femoris. These would be assessed later unless they are reported by the client as tender or part of a pain pattern that recognizes these muscles. When I needle a muscle Trigger Point the response looked for is a twitch or a dull ache or heavyness or a reproduction of the pain. After the needling the pain should have subsided. The needle is used to find and release tight stuck muscle tissue. The amount of work done on a particular treatment will depend on the clients comfort and tolerance. Ususually only around 5 or so of the above muscles will be needled in a treatment. Bruising and discomfort or heavyness for up to 12 hours after treatment and sometimes as long as a week can occur. A series of 6 treatments should be enough to resolve even difficult cases. If however the pain still in not resolved then tendon attachments will be assessed for tenderness. If these are tender and relate to the pain then it is assumed there is some tendon weakness or damage leading to the muscle trigger points being activated despite being released previously. In this case then dextrose can be introduced to induce the regrowth of the tendon. This can profoundly improve the muscle function and thus reduce the pain in the area. If there is still slow progress then Herbal medicine can be used to increase the circulation and strengthen the bodies resources to help heal and calm the pain in the foot. Other complications can be disease, smoking and poor diet or emotional health. Usually one will see a direct change in the first treatment it is usually just a matter of seeing how long it lasts. Sometimes one or two treatments are enough along with other interventions and self care. If not then we need to add other components to support the body in its imbalance. Herbal patent remedies for heel and foot pain can include Dang Gui Di Huang Yin Wan, (Tangkuei and Rehmannia Decoction) for KIdney and Liver Yin deficiency where you can see circulation is poor and problem is chronic. In a more acute healthy person I would recomend TCM along with Myofacial Trigger point theory make for a powerful combination for any pain problem. In this case of plantar pain we also have orthotics as well as a wealth of physiotherapy information one can draw upon to prevent the recurrance of this debilitating pain. I hope this is helpful for clients and practitioners alike. I have found this approach to be effective and I encourage more to use this protocol. I want to reference the study I drew from to develop part of this treatment. www.jfootankleres.com/content/4/1/5/table/T1 | ||||||||
Monday, December 17, 2012
How I Treat Plantar Fasciitis and Heel Pain.
Tuesday, December 11, 2012
WHY DO ACUPUNCTURISTS USE NEEDLES
(A humourous explanation of why I am still an acupuncturist)
"One Small Needle Cures a Thousand Illnesses”. Ancient Chinese Saying.
Many people do not like needles and as an acupuncturist I do not really like them either however I am growing to love them as the years go by.
If anything worked better than a needle I would most certainly go for it and use that rather than having to nurse people through the anxiety of their first acupuncture experience. I say first because most after one session kinda get it and see the light so to speak. Often just one acu-point is enough to convince one that hey there is nothing to it. As in did you put it in yet? Is is really done I didn't feel anything. And yes this is true and no exaggeration and you are being a bit ridiculous if you are still convinced the needles are to scarey.
So this is for you newbies who are still traumatized by nurse Kratchet in grade one getting your booster shot. I don't stab people I gently place the needles in the appropriate feel good spots not inside your deltoid muscle tendon attachment which hurts for a good minute or two. I do not inject a burning substance either.
Also the "needle" if you can call it that is more of a filament or a wire not a needle for it has no hole in the middle. In fact you can fit 5 acupuncture needles inside one hypodermic. I actually proved it just now.
There is more like 4.5 but you get the idea and if you translate the amount of possible discomfort by the size well right of the bat you have about 10 times less discomfort from an acupuncture needle. No doubt this is logarithmic scale as well.
So also the needles or filaments are coated to be extra smooth, microscpopically sharpened to be again extra pain free. Also the method of inserting the needles is practiced for at least a month or so on potatoes, oranges and all sorts of fruit before even attempting on one self. And yes the next level of training is on oneself for a while to get a feel for painless insertion. Then you get to try it on your classmates for a good year or so. They are not very forgiving patients and if you are not gentle then you are not getting any practice next class.
So after all that then you try it under supervision of your professor on some well chosen patients. This you do for another year. Then finally you are ready to insert needles safely into where ever on the body they are needed.
So this is why I started to like needles one I used them so much it was a relationship that was well developed and nurtured for four years before even practising. Also the so called pain people fear is always less than any other therapy I know.. It is even less painful than swallowing a pill.
I still do allot of massage and when I do it is always amazing how you can press your elbow into a muscle and still it does not even budge. That sore knot sometimes will never go away. But, a small needle painlessly almost mysteriously placed and magic it just melts away. It is amazing.
Also I have massaged shoulders for a half hour and little or no improvement. Two needles and in 5 seconds the shoulder pain disappears and mobility increases. The main reason I am learning to love needles as well as my clients is they work magic. Well scientifically tested magic for you sceptics wanting to sound alert bells. He said "Magic" I smell woo woo here. Calm down it is just a muscle twitch its not really magic.
Another reason I like needles is because I only have two thumbs. Yea so you may say me two. Well in this fast paced world what if you don't have time to spend an hour pressing on more than a few points. What if you want to press on a few areas for a long time. Well that's what needles are for. They allow one to stimulate multiple areas at the same time. As an acupunturist you now have not two but ten or more thumbs all working painlessly in concert with very little effort on your part. If you see a few clients an hour you can multiply that by up to ten so its like having 100 thumbs. They can all work away pressing while you have a nice cup of herbal tea and check on the rest of your schedule for the day or your blog for that matter. Isn't that great. No sore hands just happy clients.
Whats not to love about that. Am I starting to get your attention why needles are really the greatest health invention yet.
Needles even can replace exersize. This sounds rediculous does it not. But its true. You can stimulate blood flow, energize limbs, organs all in the same way exersize does. This is great for bedridden people or tired stiff or sick people. You don't need to walk you can even help asthma and breathing with needles. Whats not to love.
Now you might still be wondering or thinking about the movie Hell Raiser one of the worst horror films ever but everyone seems to know it. So I will say many famous movie stars and not so famous housewives love to have needles in thier face. What? Thats disgusting thats terrible I am never getting acupunture period now. That is it. BUT WAIT. Why do they do this well... its because it removes wrinkles and makes you look years younger. True fact. It is less painful than a facial or a scrub. The results are instant and last for years often. So what is not to love about that. Painless, natural and beautiful. Yes acupunture needles make you look beautiful. I am ashamed to say it but many of my clients come only for that very reason. They love the results of getting needles in their wrinkles.
So needles work your muscle knots out instantly, are painless, remove wrinkles, allow you to have multiple areas treated and clients treated at the same time these are just a few reasons I am starting to Love Needles.
You might wonder why it is the oldest documented medicine, the most popular health care in the world by population anyway and why it just won't go away. Now we are seeing Chiropractors, Physiotherapists, Medical Doctors, Naturopaths, Nurses and a few other medical professionals using Needles. With all the tools they have why would they want to scare their patients away with needles. Well I would say because they just work so great on pain problems especially.
So in why do we use needles? Only for one reason and thats because they work better than massage, counselling, exersize, stretching, herbal medicine if they did not I personally would avoid them altogether. Why go through the hassle the insurance the protocols to avoid infection, the everything they are needles and a medical sharp at that. Why do that? Because I want to help people feel better, be better and to make a better world by empowering people to achieve their best.
Sounds lofty I know but it has been only through using a simple thin steel filament that has given me the most satisfaction the best results and a feeling of real pride in what I do. It is not for the money thats for sure anything else would be more lucrative than acupuncture. I have some attachment to needles as you can see but I am always looking for the next best thing. So far I have not seen it accept for maybe injections into muscles but that is a bigger needle and another blog. Lasers might be the ticket we will see.
I hope when you experience the needle guiding your body to create a new healing reaction you remember all the reasons why you decided to use needles for your healing too. Oh yea and I forgot to mention the wonderful euphoria you get from acupuncture that lasts often the whole day.
(A humourous explanation of why I am still an acupuncturist)
"One Small Needle Cures a Thousand Illnesses”. Ancient Chinese Saying.
Many people do not like needles and as an acupuncturist I do not really like them either however I am growing to love them as the years go by.
If anything worked better than a needle I would most certainly go for it and use that rather than having to nurse people through the anxiety of their first acupuncture experience. I say first because most after one session kinda get it and see the light so to speak. Often just one acu-point is enough to convince one that hey there is nothing to it. As in did you put it in yet? Is is really done I didn't feel anything. And yes this is true and no exaggeration and you are being a bit ridiculous if you are still convinced the needles are to scarey.
So this is for you newbies who are still traumatized by nurse Kratchet in grade one getting your booster shot. I don't stab people I gently place the needles in the appropriate feel good spots not inside your deltoid muscle tendon attachment which hurts for a good minute or two. I do not inject a burning substance either.
Also the "needle" if you can call it that is more of a filament or a wire not a needle for it has no hole in the middle. In fact you can fit 5 acupuncture needles inside one hypodermic. I actually proved it just now.
There is more like 4.5 but you get the idea and if you translate the amount of possible discomfort by the size well right of the bat you have about 10 times less discomfort from an acupuncture needle. No doubt this is logarithmic scale as well.
So also the needles or filaments are coated to be extra smooth, microscpopically sharpened to be again extra pain free. Also the method of inserting the needles is practiced for at least a month or so on potatoes, oranges and all sorts of fruit before even attempting on one self. And yes the next level of training is on oneself for a while to get a feel for painless insertion. Then you get to try it on your classmates for a good year or so. They are not very forgiving patients and if you are not gentle then you are not getting any practice next class.
So after all that then you try it under supervision of your professor on some well chosen patients. This you do for another year. Then finally you are ready to insert needles safely into where ever on the body they are needed.
So this is why I started to like needles one I used them so much it was a relationship that was well developed and nurtured for four years before even practising. Also the so called pain people fear is always less than any other therapy I know.. It is even less painful than swallowing a pill.
I still do allot of massage and when I do it is always amazing how you can press your elbow into a muscle and still it does not even budge. That sore knot sometimes will never go away. But, a small needle painlessly almost mysteriously placed and magic it just melts away. It is amazing.
Also I have massaged shoulders for a half hour and little or no improvement. Two needles and in 5 seconds the shoulder pain disappears and mobility increases. The main reason I am learning to love needles as well as my clients is they work magic. Well scientifically tested magic for you sceptics wanting to sound alert bells. He said "Magic" I smell woo woo here. Calm down it is just a muscle twitch its not really magic.
Another reason I like needles is because I only have two thumbs. Yea so you may say me two. Well in this fast paced world what if you don't have time to spend an hour pressing on more than a few points. What if you want to press on a few areas for a long time. Well that's what needles are for. They allow one to stimulate multiple areas at the same time. As an acupunturist you now have not two but ten or more thumbs all working painlessly in concert with very little effort on your part. If you see a few clients an hour you can multiply that by up to ten so its like having 100 thumbs. They can all work away pressing while you have a nice cup of herbal tea and check on the rest of your schedule for the day or your blog for that matter. Isn't that great. No sore hands just happy clients.
Whats not to love about that. Am I starting to get your attention why needles are really the greatest health invention yet.
Needles even can replace exersize. This sounds rediculous does it not. But its true. You can stimulate blood flow, energize limbs, organs all in the same way exersize does. This is great for bedridden people or tired stiff or sick people. You don't need to walk you can even help asthma and breathing with needles. Whats not to love.
Now you might still be wondering or thinking about the movie Hell Raiser one of the worst horror films ever but everyone seems to know it. So I will say many famous movie stars and not so famous housewives love to have needles in thier face. What? Thats disgusting thats terrible I am never getting acupunture period now. That is it. BUT WAIT. Why do they do this well... its because it removes wrinkles and makes you look years younger. True fact. It is less painful than a facial or a scrub. The results are instant and last for years often. So what is not to love about that. Painless, natural and beautiful. Yes acupunture needles make you look beautiful. I am ashamed to say it but many of my clients come only for that very reason. They love the results of getting needles in their wrinkles.
So needles work your muscle knots out instantly, are painless, remove wrinkles, allow you to have multiple areas treated and clients treated at the same time these are just a few reasons I am starting to Love Needles.
You might wonder why it is the oldest documented medicine, the most popular health care in the world by population anyway and why it just won't go away. Now we are seeing Chiropractors, Physiotherapists, Medical Doctors, Naturopaths, Nurses and a few other medical professionals using Needles. With all the tools they have why would they want to scare their patients away with needles. Well I would say because they just work so great on pain problems especially.
So in why do we use needles? Only for one reason and thats because they work better than massage, counselling, exersize, stretching, herbal medicine if they did not I personally would avoid them altogether. Why go through the hassle the insurance the protocols to avoid infection, the everything they are needles and a medical sharp at that. Why do that? Because I want to help people feel better, be better and to make a better world by empowering people to achieve their best.
Sounds lofty I know but it has been only through using a simple thin steel filament that has given me the most satisfaction the best results and a feeling of real pride in what I do. It is not for the money thats for sure anything else would be more lucrative than acupuncture. I have some attachment to needles as you can see but I am always looking for the next best thing. So far I have not seen it accept for maybe injections into muscles but that is a bigger needle and another blog. Lasers might be the ticket we will see.
I hope when you experience the needle guiding your body to create a new healing reaction you remember all the reasons why you decided to use needles for your healing too. Oh yea and I forgot to mention the wonderful euphoria you get from acupuncture that lasts often the whole day.
Monday, December 3, 2012
NEVER ICE AN INJURY HERE IS WHY.
RICE is WRONG?
RICE Rest Ice Compression and Elevation is considered the standard for sprains and muscle injury. Here is a short review of why MECH Movement, Elevation, Compression and Heat is better. I have looked at numerous studies from various sports medicine sources in this short review to convince you next time not to use ice on your next sports injury.
As a Traditional Chinese Medicine practitioner we have always said heat is better for circulation and one should never use ice ever.
However, most people do not buy into this theory despite its 2000 years success so we better use some science to convince all you folk why ice does not do anything to help an injury old or new.
Firstly Why Ice? Well most would say to reduce swelling and pain. Well if you want to reduce pain then it will work great however it will not help the healing or the swelling of the area. Also for traumatic injury that is so painful there is a risk of shock then ice would be recommended just for the pain. However, most medical professionals say incorrectly yes ice reduces swelling in fact here is a quote from a spine health web site. I think you will find most medical professionals agree with this.
Ice should be applied soon after the injury occurs. The coldness makes the veins in the tissue contract, which reduces circulation in the area. After the cold compress is removed, the veins overcompensate and dilate. Once that happens, the blood rushes into the area and brings with it the nutrients necessary to heal the injured area.
A review of studies with cryotherapy on acute sprain and concluded based on practice expert opinion that ice is good.
However there was only one study that concluded that ice was good out of all the 66 studies reviewed. It was also stated that there was conflicting outcomes in the other studies. This is the kind of information that led me to believe perhaps RICE is WRONG. Looking closer we can find a few reviews that try to convince one that RICE is the right way to go.
For example a 2007 review evaluated 66 publications and found only 1 randomized controlled trial conducted on humans. The intervention in this trial involved applying cold gel 4 times a day for the first 14 days after the injury. The control group received a room-temperature gel application; neither group was aware of the temperature differential.
The study found significant reduction in pain at
rest, pain with movement, and functional disability at intervals of 7, 14, and 28 days post injury (P<.001) among patients receiving cold-gel applications. Patients receiving cold-gel treatment also reported increased satisfaction with treatment compared with the controls. At 28 days, cold-gel treatment patients scored 71 on a 100-point satisfaction scale compared with 44 for controls (P<.001). Inconclusive results or significant design flaws limited the validity of all other trials cited in this review.
Collins NC. Is ice right? Does cryotherapy improve
outcome for acute soft tissue injury? Emerg Med J.
2008;25:65-68.
According to this it would seem the coolness seemed to help. This would make one think well perhaps RICE is RIGHT.
But lets look at the physiology. When an injury occurs the swelling actually has nothing nothing to do with circulation of blood and the swelling fluid from the lymphatic system is made of large protiens too big to be taken up by the blood vessels so the blood circulation part kind of misses the whole point. To reduce swelling you need to increase the lymphatic drainage of the area injured.
Here is a detailed explanation of what happens with ice.
"When ice is applied to a body part for a prolonged period, nearby lymphatic vessels begin to dramatically increase their permeability (lymphatic vessels are ‘dead-end’ tubes which ordinarily help carry excess tissue fl
Here is another review of ice therapy from various sources finding there is no proof that ice therapy improves injury outcomes.
“Is Ice Right? Does Cryotherapy Improve Outcome for Acute Soft Tissue Injury?” JEM, 2008; Feb. 25; 65–68 Abstract: Aims: The use of ice or cryotherapy in the management of acute soft tissue injuries is widely accepted and widely practiced. This review was conducted to examine the medical literature to investigate if there is evidence to support an improvement in clinical outcome following the use of ice or cryotherapy.
Methods: A comprehensive literature search was performed and all human and animal trials or systematic reviews pertaining to soft tissue trauma, ice or cryotherapy were assessed. The clinically relevant outcome measures were: (1) a reduction in pain; (2) a reduction in swelling or edema; (3) improved function; or (4) return to participation in normal activity.
Results: Six relevant trials in humans were identified, four of which lacked randomization and blinding. There were two well conducted randomized controlled trials, one showing supportive evidence for the use of a cooling gel and the other not reaching statistical significance. Four animal studies showed that modest cooling reduced edema but excessive or prolonged cooling is damaging. There were two systematic reviews, one of which was inconclusive and the other suggested that ice may hasten return to participation.”
Conclusion: There is insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries.
The interesting point of all this is none of the studies looked at compression or movement of the lymphatic system.
If one looks at the definitions of how the lymph system works it is like a vacuume type pump. Protiens and water in the interstitial connective tissue can only be moved by mechanical means. That is muscle movement, stretching and massage or compression.
The drainage happens when sections of the lymphatic system pulsate. The dilation and contraction like when walking for example create a paristalsis. This is helped by the nerves that control the lymph vessels and how they absorb and coordinate the suction of the swelled or injured area.
Ice will numb the nerves controlling the absorption and the polarization and mechanical reactions of the lymph vessels. This is why it will cause a reversal of the fluid. And compression and some stretching and movement will increase the vasomotor lymph drainage.
The action of external mechanical factors like muscle movements, pulsation of arteries as well as the diaphragm when breathing all help to make the lymph system work. But placing a bandage on the injury with pressure while moving gently will do the most to enhance the drainage of swelling. Also to enhance one would place a tens unit and electrically stimulate the muscles above and below the injury to create a continuous pulsing to help move the fluid.
Gerald Weissmann, editor of the Federation of American Societies for Experimental Biology journal, said: “For wounds to heal we need controlled inflammation, not too much, and not too little.
RICE Rest Ice Compression and Elevation is considered the standard for sprains and muscle injury. Here is a short review of why MECH Movement, Elevation, Compression and Heat is better. I have looked at numerous studies from various sports medicine sources in this short review to convince you next time not to use ice on your next sports injury.
As a Traditional Chinese Medicine practitioner we have always said heat is better for circulation and one should never use ice ever.
However, most people do not buy into this theory despite its 2000 years success so we better use some science to convince all you folk why ice does not do anything to help an injury old or new.
Firstly Why Ice? Well most would say to reduce swelling and pain. Well if you want to reduce pain then it will work great however it will not help the healing or the swelling of the area. Also for traumatic injury that is so painful there is a risk of shock then ice would be recommended just for the pain. However, most medical professionals say incorrectly yes ice reduces swelling in fact here is a quote from a spine health web site. I think you will find most medical professionals agree with this.
Ice should be applied soon after the injury occurs. The coldness makes the veins in the tissue contract, which reduces circulation in the area. After the cold compress is removed, the veins overcompensate and dilate. Once that happens, the blood rushes into the area and brings with it the nutrients necessary to heal the injured area.
A review of studies with cryotherapy on acute sprain and concluded based on practice expert opinion that ice is good.
However there was only one study that concluded that ice was good out of all the 66 studies reviewed. It was also stated that there was conflicting outcomes in the other studies. This is the kind of information that led me to believe perhaps RICE is WRONG. Looking closer we can find a few reviews that try to convince one that RICE is the right way to go.
For example a 2007 review evaluated 66 publications and found only 1 randomized controlled trial conducted on humans. The intervention in this trial involved applying cold gel 4 times a day for the first 14 days after the injury. The control group received a room-temperature gel application; neither group was aware of the temperature differential.
rest, pain with movement, and functional disability at intervals of 7, 14, and 28 days post injury (P<.001) among patients receiving cold-gel applications. Patients receiving cold-gel treatment also reported increased satisfaction with treatment compared with the controls. At 28 days, cold-gel treatment patients scored 71 on a 100-point satisfaction scale compared with 44 for controls (P<.001). Inconclusive results or significant design flaws limited the validity of all other trials cited in this review.
Collins NC. Is ice right? Does cryotherapy improve
outcome for acute soft tissue injury? Emerg Med J.
2008;25:65-68.
According to this it would seem the coolness seemed to help. This would make one think well perhaps RICE is RIGHT.
But lets look at the physiology. When an injury occurs the swelling actually has nothing nothing to do with circulation of blood and the swelling fluid from the lymphatic system is made of large protiens too big to be taken up by the blood vessels so the blood circulation part kind of misses the whole point. To reduce swelling you need to increase the lymphatic drainage of the area injured.
Here is a detailed explanation of what happens with ice.
"When ice is applied to a body part for a prolonged period, nearby lymphatic vessels begin to dramatically increase their permeability (lymphatic vessels are ‘dead-end’ tubes which ordinarily help carry excess tissue fl
uids
back into the cardiovascular system). As lymphatic permeability is
enhanced, large amounts of fluid begin to pour from the lymphatics ‘in
the wrong direction’ (into the injured area), increasing the amount of
local swelling and pressure and potentially contributing to greater
pain.” The use of Cryotherapy in Sports Injuries,’ Sports Medicine, Vol.
3. pp. 398-414, 1986
So according to Sports medicine physiology of cold the use of ice will increase the swelling not decrease it.
Dr. Nick DiNubile, Editor in Chief of The Physician And Sports Medicine Journal (physsportsmed.com) is quoted as saying in response to icing and anti inflammatory meds “Seriously, do you honestly believe that your body’s natural inflammatory response is a mistake?” He bases this on an estimated 2 million years of evolution and that early humans no doubt had numerous sprains and strains.
Dr DiNubile also goes on to suggest that the use of ice is misunderstood on a basic physiological level by most medical professionals. The use of ice can in fact slow down recovery and impair the bodies natural healing response. From this we could conclude that using RICE as a first aid in the long term would lead to a poorly healed injury leading to longer recovery. He also says that to move the lymph fluid associated with swelling you need compression and muscle movement. Or a manual massage would also help.
This might be why we see so many inconsistencies in the use of ice among medical professionals. This is because the result of reduction of swelling would not be because of ice but compression and muscle movement.
Here is a study showing how inconsistent one of the most common medical practices is in sports medical textbooks. In 45 sports medicine textbooks no consensus was found in the use of ice therapy.
Dr. Nick DiNubile, Editor in Chief of The Physician And Sports Medicine Journal (physsportsmed.com) is quoted as saying in response to icing and anti inflammatory meds “Seriously, do you honestly believe that your body’s natural inflammatory response is a mistake?” He bases this on an estimated 2 million years of evolution and that early humans no doubt had numerous sprains and strains.
Dr DiNubile also goes on to suggest that the use of ice is misunderstood on a basic physiological level by most medical professionals. The use of ice can in fact slow down recovery and impair the bodies natural healing response. From this we could conclude that using RICE as a first aid in the long term would lead to a poorly healed injury leading to longer recovery. He also says that to move the lymph fluid associated with swelling you need compression and muscle movement. Or a manual massage would also help.
This might be why we see so many inconsistencies in the use of ice among medical professionals. This is because the result of reduction of swelling would not be because of ice but compression and muscle movement.
Here is a study showing how inconsistent one of the most common medical practices is in sports medical textbooks. In 45 sports medicine textbooks no consensus was found in the use of ice therapy.
Objective: To study ice therapy guidance in sports medicine textbooks.
Data Sources: A systematic search of a convenience sample of textbooks.
Study Selection: 45 general sports medicine texts were included in the study.
Data Extraction: The indices and chapter headings of
each text were searched using key words ice, cryotherapy, soft tissue
injury, muscle, and bruise.
Data Synthesis: In 17 of the textbooks, there was no
guidance on the duration, frequency, or length of ice treatment or on
the use of barriers between ice and the skin. Advice on treatment
duration was given in 28 texts but recommendations differed depending on
the particular ice therapy, injury location, or severity. There was
considerable variation in the recommended duration and frequency of
advised treatments.
Conclusion: There was little guidance in the standard
textbooks on ice application, and the advice varied greatly. There is a
need for evidence-based sport and exercise medicine with a consensus on
the appropriate use of ice in acute soft tissue injury.
Clinical Journal of Sport Medicine:
April 2001 - Volume 11 - Issue 2 - pp 67-72
Here is another review of ice therapy from various sources finding there is no proof that ice therapy improves injury outcomes.
“Is Ice Right? Does Cryotherapy Improve Outcome for Acute Soft Tissue Injury?” JEM, 2008; Feb. 25; 65–68 Abstract: Aims: The use of ice or cryotherapy in the management of acute soft tissue injuries is widely accepted and widely practiced. This review was conducted to examine the medical literature to investigate if there is evidence to support an improvement in clinical outcome following the use of ice or cryotherapy.
Methods: A comprehensive literature search was performed and all human and animal trials or systematic reviews pertaining to soft tissue trauma, ice or cryotherapy were assessed. The clinically relevant outcome measures were: (1) a reduction in pain; (2) a reduction in swelling or edema; (3) improved function; or (4) return to participation in normal activity.
Results: Six relevant trials in humans were identified, four of which lacked randomization and blinding. There were two well conducted randomized controlled trials, one showing supportive evidence for the use of a cooling gel and the other not reaching statistical significance. Four animal studies showed that modest cooling reduced edema but excessive or prolonged cooling is damaging. There were two systematic reviews, one of which was inconclusive and the other suggested that ice may hasten return to participation.”
Conclusion: There is insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries.
The interesting point of all this is none of the studies looked at compression or movement of the lymphatic system.
If one looks at the definitions of how the lymph system works it is like a vacuume type pump. Protiens and water in the interstitial connective tissue can only be moved by mechanical means. That is muscle movement, stretching and massage or compression.
The drainage happens when sections of the lymphatic system pulsate. The dilation and contraction like when walking for example create a paristalsis. This is helped by the nerves that control the lymph vessels and how they absorb and coordinate the suction of the swelled or injured area.
Ice will numb the nerves controlling the absorption and the polarization and mechanical reactions of the lymph vessels. This is why it will cause a reversal of the fluid. And compression and some stretching and movement will increase the vasomotor lymph drainage.
The action of external mechanical factors like muscle movements, pulsation of arteries as well as the diaphragm when breathing all help to make the lymph system work. But placing a bandage on the injury with pressure while moving gently will do the most to enhance the drainage of swelling. Also to enhance one would place a tens unit and electrically stimulate the muscles above and below the injury to create a continuous pulsing to help move the fluid.
Gerald Weissmann, editor of the Federation of American Societies for Experimental Biology journal, said: “For wounds to heal we need controlled inflammation, not too much, and not too little.
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