Is Ice Application a Myth?
The traditional advice in dealing with an acute injury was to apply ice immediately. The idea being that this would reduce swelling and therefore accelerate the recovery and return to sport. Swelling, however, is the bodies attempt to aid recovery and is the natural response to a trauma.
The question is: has the body got it wrong?
Would you recover more quickly if you didn’t swell and, if so, why would your natural response be to prolong your recovery and make you worse by inducing swelling?
Where did the recommendation for Ice Application Originate?
Ice application was popularised by Dr. Gabe Mirkin in 1978 in his “Sports Medicine Book” publication. More recently, ice baths as a means of expediting recovery after exercise has been used by many amateur and professional teams. Some athletes swear by them while other experts proclaim that there is no evidence for its use and advise against it. Many experts believe that studies suggesting positive responses from ice application are of poor quality and lacking sufficient numbers.
Taken in its totality, the evidence for ice application is very mixed and far from overwhelming. In fact, Dr. Mirkin, who first developed the R.I.C.E. (Rest, Ice, Compression & Elevation) protocol has since agreed that the protocol is unlikely to be best practice in dealing with an acute injury.
Minimising inflammation is often touted as the reasoning behind ice application but perhaps it is time to question whether inhibiting the inflammatory process is of any value. Inflammation is a key component of the healing process and plays a role in minimising further tissue damage and facilitating tissue repair. Therefore, slowing the inflammatory process is likely to delay the healing process.
An analysis of the research published in the Journal of Emergency Medicine in 2008 reviewed the available research on the application of cold therapy. The authors concluded that there is ‘insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries.’
What Happens After An Acute Injury?
Generally, the more severe the injury and the greater the blood supply to an area, then the greater the degree of inflammation. After injury, the blood vessels supplying the injured site dilate to facilitate the supply of immune cells to the injured site. These immune cells pass through the vessels and clear the debris from the injury site prior to stimulation of other growth factors that act to stimulate the tissue repair process.
The application of ice causes the blood vessels to constrict thus impairing the immune response required for healing.
Research demonstrates that blocking the inflammatory process inhibits the release of tissue growth factors such as IGF-1.
What does the Evidence Say About Ice Application?
A study by Lu et al. (2006) studied a group of mice who were genetically altered so as not to produce the normal inflammatory response. The mice then had a muscle injury induced in their thigh muscle. The reaction was then compared with a group of mice who were not genetically altered.
The genetically altered mice had a large reduction in the IGF-1 tissue growth factor when compared to the normal mice. This inhibited their full recovery. This research demonstrates that a normal inflammatory process is vital for tissue regeneration, partly through its production of IGF-1. It also suggests that ice application, by inhibiting this process, may inhibit recovery.
Research by Laba demonstrated no difference in pain, swelling, or ankle function between ice therapy (applied for 20 minutes) and no ice therapy
A 2012 paper reviewed the use of ice in acute ankle sprains and concluded that the use of ice in the management of ankle sprain is ‘based largely on anecdotal evidence’ and that ‘insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults.’
A review of the research based on 4 studies by Hubbard et al. concluded that cryotherapy positively affected return to work and sports
Should I use heat instead of Ice?
Research by Hoycutt et al. compared the use of an ice whirlpool applied 1 to 3 times per day for 3 days. This was compared with a group applying a heat pad for 15 minutes 1 to 3 times per day. The group applying ice returned to full activity at 13.2 days, while the heat therapy group took 33.3 days to return to full activity.
We can conclude from this that ice is definitely better than heat but heat application would never be used after an acute injury & therefore it is difficult to draw firm conclusions from this research.
Clinically, I see a lot of patients who use ice in the absence of swelling or bruising. Their logic being that they will reduce inflammation. After trauma, if inflammation is present you will generally notice that there is bruising or enlargement of the involved joint. If these are not present, then it unlikely that ice application will serve any purpose.
Bleakley CM, O’Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340 c1964. doi: 10.1136/bmj.c1964. https://www.bmj.com/content/340/bmj.c1964
Collins NC. Is ice right? Does cryotherapy improve outcome for acute soft tissue injury? Emergency Medicine Journal 2008;25:65-68. https://pubmed.ncbi.nlm.nih.gov/18212134/
Laba E. Clinical evaluation of ice therapy for acute ankle sprain injuries. NZ J Physiother. 1989;17:7–9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579462/
van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, van Dijk CN, Kerkhoffs GM. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?. J Athl Train. 2012;47(4):435-443. doi:10.4085/1062-6050-47.4.14 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396304/
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