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

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.

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.

Read more: http://www.dailymail.co.uk/health/article-1324096/Ice-injury-prevent-healing-Swelling-turned-head.html#ixzz2E4ARefHY

The above author states that ICE on an injury might block the natural human growth hormones that have been recently discovered that repair muscle. These are released in great number when an area is injured. This is another reason why ICE does not help anything but pain. 

Dr. Sherwin Ho  has already published articles in 1990 on the negative effects of ice, where he showed that as little as five minutes of icing a knee can decrease both blood flow to the soft tissues and skeletal metabolism. He found that icing a knee for 25 minutes decreases blood flow and skeletal metabolism another 400 percent! Healing is hindered by a decrease in blood flow and metabolism to the area. Icing increases the chance of incomplete healing by decreasing blood flow to the injured ligaments and tendons. This increases the chance of re-injury or the development of chronic pain. 

This is especially true for ligaments and tendons which need blood flow to heal. 

It gets worse not only does ice impair healing it can even damage nerves. The Louisiana State University School of Medicine reported on five athletes who obtained nerve palsies (nerve injuries usually to the peroneal nerve that moves the foot up) from too much ice around the knee. The conclusion of the article was, "Applying ice for more than 30 minutes, and preferably for not more than 20 minutes, should be strictly avoided."

 

 Dr. William McMaster of the University of California at Irvine, a well-known researcher on the use of ice therapy and its use in athletics cautions its use because "Cold application or ice has been shown to depress the excitability of free nerve endings and peripheral nerve fibers, increasing pain threshold. This effect is of great value in acute treatment; however, its judicious use can contribute to serious injury. The loss of protective pain sensibility after local icing is probably a contraindication to athletic participation. Additional effects of cold application include: decrease in blood flow, decrease in inflammatory response, and decrease in local edema protection."

 

Wow this is getting serious. Ice not only does not reduce inflamation it increases the chances of future inflamation. 

 

 Collagen tissue, which makes up ligaments, is normally extensible and exhibits primarily elastic properties, when it is stressed it can stretch a little. However, when a ligament is cooled, it becomes stiffer and more prone to injury because it cannot stretch when it is stressed. So here we finally get to heat. 

When you have an injury you wrap and protect it stretch gently to the edge of pain. And when the swelling starts to subside use heat and continue to stretch and move as much as you can with the pain. 

There is not allot of information about heat on acute injuries and perhaps it is best not to use heat untill the injury swelling starts to subside. 

In conclusion I hope this is convincing enough for all medical professionals to stop the use of ice on injuries. Compression and light movement and elevation are best and heat as soon as one can see the swelling is starting to come down. Then with the easing of the heat one can start to move the muscles around the area of injury and stimulate the lymphatic movement. 

Trust in the bodies innate healing system. 

And lastly for the pain acupuncture works great on an acute sprain helping to support the bodies natural process.