Ice not recommended for soft tissue injury treatment (2019)
blogs.bmj.com
blogs.bmj.com
Rest Ice Compression Elevation may be wrong, but it is at least easy to understand, memorize, and explain. When my friend hurts their ankle, I want to pass on the latest, vetted wisdom. I don’t want to sound like a jackass saying, “O is for optimism. But we are not done yet. V is for vascularization. You don’t have much control over it, but we need to the round out the word LOVE. The third E is for …”
> I'm a person [not a robot]!
> optimuspaul
So really this is preaching anti-education. Do not seek out information about your injury.
From the paper:
> E for educate
> Therapists should educate patients on the benefits of an active approach to recovery. Passive modalities, such as electrotherapy, manual therapy or acupuncture, early after injury have insignificant effects on pain and function compared with an active approach, and may even be counterproductive in the long term. Indeed, nurturing an external locus of control or the ‘need to be fixed’ can lead to therapy- dependent behaviour. Better education on the condition and load management will help avoid overtreatment. This in turn reduces the likelihood of unnecessary injections or surgery, and supports a reduction in the cost of healthcare (eg, due to disability compensation associated with low back pain). In an era of hi- tech therapeutic options, we strongly advocate for setting realistic expectations with patients about recovery times instead of chasing the ‘magic cure’ approach.
https://progressiveptandrehab.com/rice-and-meat-physical-the...
TLDR; IRRC: Don't take anti-inflammatory, don't keep it stationary, don't fight swelling at all, but do keep it moving and teach your body to avoid the motion that caused the injury.
So easy to remember, since, you know, we damaged our meat in these types of injury.
In the short term it may be beneficial to avoid a certain muscle or area, but eventually you have to get it turned back on too.
Boy, really? I was interested until stumbling on those bits. We've certainly reached peak-acronym.
[edit] And now I see it's an old story.
> An Ontario man suffering from an incurable neurological disease has provided CTV News with audio recordings that he says are proof that hospital staff offered him medically assisted death, despite his repeated requests to live at home.
> Roger Foley, 42, who earlier this year launched a landmark lawsuit against a London hospital, several health agencies, the Ontario government and the federal government, alleges that health officials will not provide him with an assisted home care team of his choosing, instead offering, among other things, medically assisted death.
https://www.catholicnewsagency.com/news/252991/canadian-vete...
> In 2021, there were 10,064 MAID provisions reported in Canada, accounting for 3.3% of all deaths in Canada.
From an official government report: https://archive.ph/xD0wD#selection-3057.0-3057.107
Numbers aren't out yet for 2022, and in 2023 it opens up to mental illness as well.
"Couldn't they have come up with something simpler, since the healing of soft-tissue injuries is so simple?"
Basically the opposite of RICE, all 4 were focused on maximizing blood flow to the soft tissue injury. And anecdotally, I can confirm it works way better than RICE or the alternatives. I used to be out for 2-3 weeks after running issues when I used RICE, etc. After I switched to HELM I was back on the pavement the next morning.
The issue with HELM is that it can be significantly more painful than RICE, etc., as you must avoid using anti-inflammatories and painkillers.
Hippies will hate it, though.
What I discovered was that cold did feel good and did alleviate some of the discomfort from running, but for overuse induced discomfort it wasn't overall helpful to me.
Now a bit off-topic to explain what did help me with overlong runs:
What helped me the most for the wear and tear caused by long runs was getting the right shoes: some would make the lateral (furthest from the midline of my body) sides of my knees hurt, some would make the medial (closest to midline) sides of my knees hurt and when I found the right ones my knees didn't hurt. Shoes without enough padding under the ball of my foot also ended up causing me more pain than shoes with more padding.
I always alternated my runs between shoes from two different manufacturers because I found that the slight differences in the ways the shoes flexed prevented overuse injuries from running in the same shoes each day.
Finally, for some reason I would curl my toes down as I got tired and bruise a couple of my toenails. I fixed this with little soft silicon toe sleeves that I could pick up at the pharmacy.
And +1 on the shoes thing. I do the alternating shoes thing, as well. And I can tell when a pair is wearing out because I start to get little pains that grow until I replace the shoes. Some of my full-blown, need-to-take-time-off injuries have been from running in worn out shoes. Usually they wear out after 300-500 miles.
I'll have to check out the toe sleeves. Thanks for the tip.
I experience this too and wasn't sure if it was my imagination or truly indicative that I need to replace them. Your comment helps to assure me it's the latter case.
The advice about rotating shoes to prevent overuse injuries, paying attention to stress bottlenecks is general.
Bodies differ in certain ways, but I've heard the same story as the shoes from many intensive exercisers. That I've never heard from a physician.
Listen to your body.
If it hurts, and it's not muscle burn, it's tendon/ligament/worse.
Muscle burn is very obviously different to actual pain.
Just stop. Change your posture so that part of your body isn't stressed, and the actual pain goes away.
If you can't make actual pain stop hurting, take an extended break by cross training.
Don't go home for the day. Always keep your exercise routine constant, but absolutely vary it to include "low stress" fallback options for tendon/ligament strain (pushups or own bodyweight, exercise bike, swimming).
If the same part hurts again next time, you likely have a "weak" point. You will need to gradually increase intensity until the "weak" point isn't a bottleneck.
Gradually means 10% intensity growth per weak maximum, and not pushing through actual pain.
All of the above is really simple.
The question is, why isn't what "actually works" the cutesy acronym?
ICE stands for Impact, Confidence, and Ease. I think the acronym is rather stretched and awkward.
Rest, Immobilization, Cold, Elevation
The article mentions a shift from ICE to RICE (which I’m aware of) and then another shift to PRICE, which I’m not aware of— anyone know what the P stands for?
It seems like someone just wanted to invent another acronym.
Instead, they mean that you should protect the injury so that it's not exacerbated: brace it or put it in a sling, have the patient use crutches, etc.
And, given that, people talking about ice (frozen water) is fine, since that's specifically one of the things the new paper seems to be suggesting people stop doing, as well as stopping the use of anti-inflammatories.
https://university.hygger.io/en/articles/3272334-lesson-6-ic...
I didn't search beyond the first result; but it seemed clear that it was an acronym, and it wasn't expanded in the article. So there may be other ways of expanding the acronym.
"Impact" may have made it look like it's talking about an injury, but actually those acronyms you found are about prioritizing tasks in product development.
> Rehabilitation of soft tissue injuries can be complex. Over the years, acronyms guiding their management have evolved from ICE to RICE[1], then to PRICE[2] and POLICE[3].
> [1] van den Bekerom MPJ, Struijs PAA, Blankevoort L, et al. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults. J Athl Train2012;47: 435-43.
"We also question the use of cryotherapy. Despite widespread use among clinicians and the population, there is no high-quality evidence on the efficacy of ice for treating soft-tissue injuries. Even if mostly analgesic, ice could potentially disrupt inflammation, angiogenesis and revascularisation, delay neutrophil and macrophage infiltration as well as increase immature myofibres."
So more or less, the title may be correct as is.
Reading stuff like this now kinda feels like we lost a bunch of knowledge in the past two decades.
All I could find though was statements that it doesn't serve a role/gets in the way of healing, something about maybe being mainly to prevent infection at a wound site?
What you said seems reasonable, but can you point to any sources? I'd like to confirm for myself.
All this is confusing.
It can be quite difficult to use pain as a guide for those of us lucky enough to have endured chronic pain, as you build up a bunch of subconscious coping mechanisms and you are expected to experience pain when getting the broken bits moving again. So how much is too much? I have no idea. I definitely agree that pain management meds and anti-inflammatories are counter-productive though.
It's all a bit ambiguous I guess, I'd rather get updates via x-rays even if we are doing the "HOPES" and "DREAMS" approach to healing. Sorry, I mean PEACE and LOVE. I do believe in this approach to healing, I want to make that clear, there's just some rough edges in the User Experience of the approach in the doctors office I think.
I was a pretty model patient though, I was terrified of moving the arm and so it likely did sit where it needed to the whole time. I imagine others may struggle with such a direction.
I have no idea of it’s effective but it seems to have helped her.
I’m always skeptical about these sorry of things. But having had similar injuries before and having not used ice I was surprised that she could move her wrist without pain while for me it takes like a week.
In my wife’s case she has full movement and no pain. But she didn’t go back for class for 2 weeks. Make sure it had healed. Just was surprising to me that she curls move her wrist without pain.
Surprisingly, the blog has more references than the paper (and the paper mentions that).
The way I see it, swelling could be one of two things:
1) a mechanism that the body engages in order to heal or alleviate healing, similar to fevers, or
2) a negative side-effect caused by, say, inflammation or something.
There are probably studies that indicate which of the two it is, I don't know. But if it is #1, then reducing it is just a way to actively work against the body.
Inflammation is primarily to address severe trauma, like having a limb severed or torn apart. That doesn't necessarily mean it's good for all tissue damage, but evolution often can't make such fine distinctions, so our body triggers inflammatory responses even when it's counterproductive. The inconvenience a counterproductive response is much better than the death that follows from not having any response.
A lot of medicine is about controlling the body's inappropriate inflammatory responses. We don't always have a good handle yet on when the body's inflammatory response is good vs. bad in all cases, which is why the debate over icing is ongoing, but it is clear that it often isn't beneficial. I think it's also clear that icing and NSAIDS for chronic inflammation are not good ideas.
This is just not accurate, and I'd love to see your source on even the first clause here. because evolution does, in fact, make fine distinctions all over the tree of life.
Or in other words, ducks imprinting on a dog is a thing: https://www.youtube.com/watch?v=6qidueuojrc
I said evolution often can't make fine distinctions, not that it never can. The inconvenience of improper inflammation was clearly never so great that it impacted reproductive fitness, where death resulting from no inflammation clearly does.
Source?
How would an actual scientist even prove or disprove this statement?
So it could be that ice is a good thing, just like air conditioning is a good thing, but nature had no way of evolving that.
Besides trying to reduce inflammation, the other big one of course is antipyretics, or fever reducers. Fever is a big trigger for our bodies' innate immune system, both helping to denature bacterial and viral enzymes and triggering the recruitment of defense cells. Suppressing the fever unnecessarily (i.e. when the fever itself isn't causing harm) seems to have a significant effect on the body's ability to fight pathogens.
> "the use of antipyretic drugs to diminish fever correlates with a 5% increase in mortality in human populations infected with influenza virus and negatively affects patient outcomes in the intensive care unit."
While survival now at the expense of long term healing was probably a good tradeoff for our ancestors living in the wild, it likely no longer makes sense for modern people outside of emergency situations.
I want to emphasize, that this was just an explanation that I was told. No actual evidence was given.
This was from a sports medicine doctor during a conversation about our sports trainers. The doctor was also against the heavy use of cryotherapy by our trainers because, according to her, it prolonged recovery. She actually encouraged applying heat instead of cold for non-injuries (e.g., post-workout, pre-competition, etc.) where your body may not have an inflammatory response to increase blood flow to the areas and that applying cold would just increase the chance of actual injury.
Of course, the topic is very similar to all the conversations about ChatGPT: are eyebrows "made" to protect the eyes from dripping sweat? No, because evolution has no intention. But it sure was convenient.
However, it could be the case that icing injuries is a good idea if you need to perform the next day (or otherwise soon) but a bad idea if you want to heal the best/soonest that you can.
Or it could all just be nonsense, no shortage of that, no matter how popular.
I hope this research continues until it's conclusive one way or the other and if it's the opposite of what I (and that paper) suggest then we should have a good explanation for that.
That's not to say I don't take painkillers, but that I think a lot about the tradeoffs before I take one. For instance, I didn't take any to relieve vaccination symptoms even though that was the standard advice by the healthcare provider as I figured why would I want to interrupt my bodies response to a pathogen at the precise time it's learning to combat it? (There are some studies that suggest this is true, although the scale of it is a little fuzzy).
What usually tips the balance for me to take a mild painkiller is if the pain is bad enough to genuinely stop me sleeping, in that case I'm buying the healing mechanism that sleep provides.
Some of those responses are of the form "hurt the pathogen more than it hurts you" and since the vaccine isn't a real threat all they do is hurt you.
https://www.cdc.gov/vaccines/covid-19/clinical-consideration...
When you're in a stressful situation at work, your body can't tell the difference between that and "Oh no, we spotted a material threat to our life", so it reacts in ways that would make fight or flight easier, not in ways that help you handle the real situation.
If your liver fails and you get a transplant, your body sees "ah, a foreign invader", and will set about the task of rejecting the new liver, despite it being very important for your wellbeing.
Applying the logic of "your body knows" is probably not in your best long term interest. In purely evolutionary terms, getting a bad enough injury that you require medical attention should mean you just die because you weren't strong enough to survive. Artificially saving your life is "unnatural".
Newborn babies can not survive, yet that says nothing about whether they 'should' or 'shouldn't' according to 'evolution.'
Evolution isn't goal directed, it isn't picking winners and losers.
> The Benefits of Ice Ice is not wrong or harmful. The theory that ice impedes the normal healing response by limiting inflammation is not well documented in the literature. If you have been swayed by this on the internet, I would urge you to try to research this more and scrutinize the literature. Be careful of what you see on the internet and ALWAYS seek to validate anything yourself.
Ice has plenty of benefits and clinical validation.
Proper application of cryotherapy can reduce secondary injury and reduce edema formation if applied within the first 36 to 48 hours (remember, ice doesn’t reduce swelling after the acute injury phase, and may not play a huge role in inflammation or recovery). We do know that ice helps reduce pain, spasm, and guarding, allowing more mobility (Barber et al. 1998, Raynor et al. 2005). More than anything, ice is a convenient and potent pain reliever, so it’s ok to apply ice to ‘chronic’ conditions as a safer pain reliever at any time. In fact, cryotherapy has been shown to decrease the amount of prescription pain medications needed after surgery (Barber et al. 1998, Raynor et al. 2005).[1]
1. https://mikereinold.com/is-icing-really-bad-for-you/ (2018)
Ice has shown benefits in study and practice, and the above article has many cited studies and a critique of anti-ice articles.
I have a friend who just had knee replacement. She said the pain was excruciating, and that the best advice was ice in the first few days (she said two days), followed by heat after that. Since she's the type of person who would have access to the best medical advice, I tend to believe it.
As for claims that "the body is always right" : look up "auto-immune disease."
Maybe rather than washing wounds, it'll turn out it's best to jam them with soil to get the immune system revved up...
Which seems to me like a way to introduce mouth bacteria and cause an infection, but maybe it’s counter-intuitively beneficial?
Nevertheless, washing in tap water with soap is probably better nowadays.
Jamming an open wound into soil is going against the well established knowledge we have on how infection works.
This article / "paper" is barely a stub. No study was done and I don't think this could be called a meta-analysis, but rather a summary citing a few other articles (only 2 relevant to icing in the context of avoiding anti-inflammatories). Even if it's true, this article does nothing to support the claims and does not address reasons why ice would be used.
Are there studies proving anti-inflammatories are counterproductive?
Though it does seem to overlap some with the authors' PEACE & LOVE except with regard to analgesics. I've been hearing more and more about how NSAIDs may not be as beneficial as they've been touted. I wonder what is the current scientific consensus on them.
I had arthroscopic surgery for a torn meniscus in my knee this year. My doc (well-respected pro sports ortho in Austin) put me on ice and rather long term Naproxen (NSAID). So not every doc has gotten with or believes in the new thinking.
What I discovered anecdotally is that the swelling was never any worse, and there was no discernible difference in the time a given category of injury (twisted/sprained ankles for the most part) took to heal.
And it makes sense when you think about it, we've evolved for millions of years to deal with acute minor injuries without ice. Look at the billions of people who live without refrigeration today and engage in daily manual labor, are they continually hobbled by minor injuries? No. How ice became such a religious imperative in injury treatment I have no idea. Granted it probably makes sense in cases where the swelling/inflammation is so severe it becomes a secondary injury or just continuously painful, but for the everyday "rolled my ankle while playing house league soccer" injury? Completely unnecessary and ineffective IMO.
So what changed that it is no longer beneficial?
Ice is used as an anti-inflammatory. Because swelling often prevents movement. So since ice reduced the inflammation and swelling, it increased movement, which we've translated as "being better".
But apparently what you want is to not move and aggravate the actual injury.
We've moved from treating the symptoms to treating the cause.
Especially with things that seem obvious. Like cooling an injury with ice for instance, which seem like a good idea (or feels better anyway).
Also people have tried to keep stuff cold for ages, I'm pretty sure the folk remedy of using a slab of cold meat to cool an injury has been around longer than just the period in time that people had free access to ice.
Wouldn't it have been difficult to keep the meat cold?
Now it has been tested.
I wouldn't assume that :) Ice treatment was about pain relief, not overall benefit. I believe it also came from the world of sports science, to which a lower bar is applied due to the general non-life-or-death consequences.
why assume in the age of the internet? if it's something that tickles your curiosity just do a little research
When a part of the body is injured, stressed, or just requiring extra nutrition, it swells up. Swelling is a cure. But swelling is also painful and can lead to other problems. The most important thing to do is to make sure the area that is swelling is also getting good circulation. So a simple "pumping" approach of the muscles surrounding the swelled area should cause good flow. And swelling will be reduced.
For example: You walk a long distance with inappropriate footwear. I am talking about 20,000 steps. And this is not something you are used to. So When resting, the body floods the foot with a whole lot of nutrients. But the blood just stays there, because it will slowly and eventually flow out with movement. But the body is not moving, so it swells. Massage pumping the calves will pump the blood out and new blood will flow in. This will reduce the swelling.
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oh man, what a throwback to 2010 spam emails and blogpost comments
That being said I continuously injure myself because I am very active - all sports have a risk of injury - and have never iced. I had a really bad ankle sprain a few weeks ago where my only treatment was compression and I was operating on it and performed a 2.25x body weight back squat with no issues within three weeks. So, anecdotally, not icing and no anti-inflammatories seems to work well for me. Probably a healthy dose of being stubborn and a stickler for not missing training helps as well.
(It's not because I'm young and heal quickly - I'll be 44 in two weeks.)