Rest, Ice, Compression and Elevation are the basic functions used to describe managing an acute injury. Rest, to prevent further damage to the tissues, Compression to contain swelling, Elevation to assist with lymphatic return and Ice to prevent internal bleeding. This is all for 'directly' following an injury. Acute management of an immediate injury. There is a movement in the athletic sphere that we have to come to rely on ICE or 'cryotherapy' as a way to manage all manner of issues and injuries, when in fact we may be preventing natural healing process' that make recovery better and more efficient. In short, we have come to rely on Ice too liberally and perhaps - blindly.
A lot of people have taken the RICE principle as the 'go to' for management of injuries. "oh it hurts - ice it". This is also a practice that has been proactively endorsed by predominantly North American sports practitioners to aid recovery and to assist with maintaining peak performance. This is the challenging perspective. The whole concept of ice baths after a match and ice packs to deal with sore and aching muscles has been built into the psyche of elite teams when in fact, the science actually shows that this is not the best case scenario.
I have come across some interesting viewpoints being discussed in the USA regarding challenging the long held conceptions of injury management and prevention and how we treat injury. The views are inflammatory, inciting debate and challenging concepts that have long been held to be sacrosanct in the athletic/movement field. What we must consider is that ICE IS NOT THE ANSWER. This flies in the face of everything we are taught at a basic level about injury management and I have to say that in my own experience of injury management, there is some truth in this concept.
So let's all put on the whale music, contemplate a cross legged position and put ourselves in a receptive position, because this is going to challenge a great deal of us to what we believe we should and shouldn't do in injury management.
INFLAMMATION
A lot of people suffer inflammation after injury. A pooling of the lymphatic fluid and swelling around the joints that can also be discomforting and make movement painful. THERE'S A REASON! The body needs inflammation to 'contain an injury and isolate the area for healing". It's like a natural splint, that stops you from moving the area any further. Accordingly, anything that downgrades an inflammatory response is going to have a negative impact on wound healing. In the initial stages directly following an injury, neutrophils are released to promote inflammation and attract other cells to an injury site. It is stated that some neutrophils can further damage injured muscle be releasing oxygen-free radicals that damage cell membranes. However, subsequent to this, macrophages (the pac man of the inflammatory cycle) invade the muscle fibers and 'eat up' the debris before a second wave of macrophages that are associated with muscle regeneration are released into the injury site.
“First, neutrophils rapidly invade the injury site and promote inflammation by releasing cytokines that can attract and activate additional inflammatory cells... Next, there is an increase in macrophages that invade damaged muscle fibers and phagocytose debris. Finally, there is an increase in a second subpopulation of macrophages that are associated with muscle regeneration. - ”
Thus there is a brief window where muscle fibres are exposed to potentially harmful influences early on in the inflammatory cycle. Excessive swelling can also make the area quite painful so reducing this swelling may be beneficial for pain management. However, after this, the 'good guy' macrophages are released into the site of the injury to promote mending of muscle fibres. Topical application of ICE constricts the blood flow from entering an injured area and delivering the required cells of inflammation and healing Human Growth Hormone (IGF-1 hormone) that helps to repair damaged tissues. This reduction of hormones necessary for muscle filament repair causes muscle fibres to die and can consequently delay healing or downgrade recovery.
RECOVERY AND PAIN
Ice is also shown to reduce strength, speed, endurance and co-ordination. For many weekend sports people, throwing an ice pack on an injury and then running back out onto the field is the way to 'stay tough and be a good player'. This is at the expense of your own health and recovery. Ice constricts blood flow and downgrades nerve response. You can't expect a muscle to function when it has 'been cooled'. This is why you 'warm up'. To promote cellular activity and increase blood flow to an area so that muscle fibres are fired and ready to perform.
The ice baths that have become so popular in sports based recovery programs are actually refuted by the science that addresses what icing does for tissues. Downgrading blood flow downgrades the delivery of nutrients and vital cells that are needed for rebuilding damaged tissues and promoting lymphatic return. Thus excessive cooling post activity can actually prevent the natural processes of muscle regeneration brought about by the release of IGF-1 in damaged tissues. This hormone is released by the very macrophages that enter the system during the inflammatory response. Hence, you need some of that response to create the ideal environment for tissue healing via Growth Factor Hormone secretion. There is however, evidence to support that Ice baths do have a positive effect on the Delayed Onset Muscle Soreness that many athletes suffer from after strenuous exercise. In short - it makes you feel less sore. So this is why you may see those ice plunge baths in the expensive change rooms of Real Madrid and Barcelona FC. To that I say - 'man up bitches'!
SWELLING
The body's response to injury is a pooling of fluid. Excessive swelling can be an issue as it prevents normal flow of blood and function. This can impede recovery. Swelling is also painful and can create issues for the injured person as fluid rushes into an area and begins to restrict any movement. However, the best way to control swelling is not through the application of ice but with a compression bandage. A 2004 study cited by the American Journal of Sports Medicine, found that "ice with compression had no greater effect on healing over compression alone". Swelling is also indicated by a pooling of lymph fluid. The fluid that accumulates in the interstitial space (space between the cells) following muscular contraction. This fluid movement is best assisted by stretching, elevation and light exercise post activity. contraction of surrounding muscles help to push the lymph fluid forward and along the lymphatic pathway. Thus exercise and movement is best recommended to assist with the removal of swelling. Rest is contraindicated as it would encourage more pooling of the fluid. Hence the 'swim down' or walk, or post game run down that many sporting organisations or 'teams' promote as an active way to promote recovery.
ICE AND REHABILITATION
This makes an interesting point for the rehabilitation of injuries such as ankle sprains, strains, knee twists and ligament strains. To assist with reduced swelling and fluid movement as well as delivery of nutrients, blood and lymphatic flow is encouraged. To do this, movement is needed to move the fluid through as well as promote blood flow through an area. Ice freezes - thus reducing capillary flow. This is NOT what you want when you are in the post acute phase of recovery. You want the optimal delivery of nutrients and blood and 'warmth' to the injured area and to keep this pliable and flowing. I have always encouraged my clients to apply heat before going onto the field if you are nursing an injury. It makes sense, you want the muscle to be warm and supple, not brittle and cold if you are going to be using it to kick a ball, run a field or jump explosively.
Whilst icing down after a big match may be a very bonding team experience, sitting on the porch with a shared ice bucket, taking turns to plunge your feet and knees in after each other, you may indeed be preventing the vital cellular process' that are meant to be happening in your body to aid recovery. Instead of icing down, you should all be maybe going for a swim, gentle walk or doing a yoga class together.
There is also the argument that to assist recovery you need to stress the tissue or joint a little to make it stronger. Our body responds to load. We have it inbuilt at cellular level. It has become much more common for people to be up and walking a day or two after knee surgery. This is exactly what is prescribed. No longer are we in heavy casts and on crutches for weeks upon weeks of recovery. Now you are literally walking out of the hospital, in order to promote healing and also to ensure that the tissues, heal strongly (in response to the stress being placed upon them) and completely.
“There are certain cells in our body that we can convince to become other cells. Load in tendon tells our body to turn a progenitor cell in to a tenocyte. Load in bone tells a progenitor cell to become an osteocyte.”
A case study in point comes back to a volleyball colleague who after 9 months of inactivity following a cartilage tear, has found himself still unable to return to the court due to the inherent weakness in his knee now. His atrophy of musculature was severe as he was kept off his knee for 9 months. Such was the advice of a medical professional.
So Is Ice relevant at all? YES. Even Mirkin concedes that ice can help with calming the pain and reducing any immediate bleeding trauma into the interstitial space immediately following an acute injury. HOWEVER, he does also state that this should be 10min on, 20min off for one or two rotations only.
"there is absolutely no evidence to support icing for a period any longer than 6 hours after an injury"
Dr Gabe Markin
Josh Stone a proactive and vociferous blogger on this topic from Illinois, takes it one step further and says that the only benefit of Ice application is for pain management. But is this ice management at the cost of immediate healing process' that are necessary to make the injury rehabilitate faster? I believe he has a point. a 2012 publication from the British Journal of Sports Medicine also promotes the declassification of ice as the best remedy for injury management and states unequivocally that "In reality, there is little or no evidence in the literature to support the use of RICE". The science suggests that this is not the be all and end all approach to acute injury that we once thought it was and that in the liberal approach to cryotherapy, we are perhaps trading into that western dogma of treating the symptom and not the cause.
So what of the Eastern perspective? The Chinese Medicine approach is actually one of fostering and actively promoting inflammation and thus, healing. In TCM ice and cold swells and cools - not actively recruiting an inflammatory response and thus the recruitment of the healing energy necessary for tissue and energy replenishment. Swelling and indeed bruising is the natural way to promote warmth and metabolism of cells to assist with delivery of healing, blood and Qi to an area. This is also managed with herbs and is adjusted slightly to the injury needs as it progresses from acute, to sub-acute and to rehabilitation.
There is an approach to the liberal use of ice that may be promoted amongst other conditions, especially inflammatory conditions where the benefits of battling excessive or prolonged inflammatory response is actually the primary focus. Osteoarthritis is one such condition where the body's inflammatory response is topical and actually causes necrosis and degeneration of structures as it fears a 'foreign invader'. This kind of inflammatory response does need to be downgraded and perhaps the use of ice as a pain reliever here is the most primary concern. Also downgrading the apparent 'inflammatory response' that the body is producing in response to a perceived pathogen is the primary goal and the most beneficial approach. Clearly it is not a 'one size fits all solution'.
There is also the converse argument that perhaps heat is better. But when you have a fire do you throw more fuel on the fire to try and 'burn it out'? Double fire doesn't make a burnt matchstick whole again. There is a case for using heat pre activity to help set the body in motion and to keep blood flow at a maximum level, ensuring soft tissue has plenty of blood and flow moving through it. But to put extra heat on an injury may be just as bad as putting an ice pack on it. Sometimes the body has enough knowledge to know what it is doing on its own and we just have to allow it to do that.
There is lots of evidence to suggest that we have become too reliant on our ice packs and our cryotherapy. Dare I propose it is our 'easy approach' to slapping on an ice pack that is so easy to rely upon rather than doing some extra rehabilitation work? So next time you reach for the ice bucket after lots of exercise or even icing down after an ankle sprain or twisted knee, maybe you need to rethink your approach. Do you want to snap freeze your cells or entice them to do the work they were meant to do?
Think on it.
