To Ice, or not To Ice?

To Ice, or not To Ice? That is the question for anyone in pain, right?

In 1978 Dr. Gabe Mirkin coins the acronym RICE (Rest, Ice, Compression, and Elevation) for dealing with acute injuries. Since then, RICE sweeps the nation and has become the standard for health care professionals, coaches, trainers, and even common knowledge everywhere when it comes to dealing with acute injuries. Has nothing changed since 1978? In over 35 years, have we really come no further for dealing with acute injuries? Recently in 2014, Dr. Mirkin publicly stated, “Coaches have used my RICE guideline for decades, but now it appears that both Ice and complete Rest may delay healing instead of helping.”

Before we dive into the issue of using Ice or not, we need to understand the purpose of icing, and then decide whether or not icing actually does what we are intending it to do. The “ice age” for acute injury treatment developed with the idea that inflammation is bad. Since ice promotes the stop of inflammation, and that by stopping inflammation we will increase the healing time, ice your acute injuries within the first 48 hours. With recent developments in science and literature, how accurate were we in 1978, and do we need to change anything now?

The first thing I’d like to discuss is the capacity of ice to actually remove inflammation. Through medical advances, we now know that inflammation is transported throughout the body through what is called the lymphatic system. The lymphatic system is a circulatory system that functions to transport excess fluid, protein molecules, debris, and other matter away from the tissue spaces and dump them back into the superior vena cava of the heart. The important piece to note here is that the lumphatic system is a circulatory system, much like your blood. However, the lymphatic system does not have the convenience of a heart to circulate it. In fact, lymphatic fluid can pool in one particular region if not “pushed” through the lymphatic vessels. When fluid enters into the terminal lymphatic capillaries and begins to pool, the physics of the body require body motion in order to provide a compressive force. These compressive forces propel lymphatic fluid through the lymphatic vessels and eventually back into circulation for removal.

Now that we know how inflammation is removed from an injured area we can think about the effects of ice on its ability to help, or hurt. Ice tends to slow things down. Think about any thick fluid running through a tube. A good example is toothpaste. The colder the fluid is, the slower it will move through the tube when you squeeze it. If you heated the fluid, it would move faster and require less compressive force to push through. This is similar to the effect of ice on the lymphatic drainage of inflammation. The inflammation is somewhat thick from the contents of protein, debris, and other matter. Applying ice would actually impair the ability to effectively manage lymphatic drainage and overall flow. We’ve effectively created a sludge around the injured site. It makes it tough for more inflammation to come in, which reduces swelling, but it doesn’t help the drainage, flow, or healing.

Another concept that is important to understand is permeability. Permeability is a term used to describe the “leakiness” of vessels in the body. The more permeability, the leakier the vessel is, the more “stuff” leaks out. Studies have found that prolonged periods of cold application to lymphatic vessels drastically increases their permeability. So when we apply ice and rest together, the sludge now pools in the leaky lymphatic vessels around an injured tissue. This does not promote healing and actually impairs recovery time, making it take longer to get better.

The next concept we should discuss is if in fact, the natural inflammatory response is a bad thing. We see an overabundance of anti-inflammatory treatments from ice to NSAIDs, the question is, are they overused? I would suggest, absolutely!

We now understand that Inflammation is the initiation of healing. It occurs within the first few seconds of injury. The first step is to bring in cells called macrophages and neutrophils who are the “clean up” crew to the cellular debris. Following behind the macrophages and neutrophils are progenitor cells. These cells create new tissue. They are essentially the healing cells. Because inflammation cleans the injured site and then brings in healing cells, inflammation is essential for the repair and remodeling phases of healing. If we stop this process we delay the arrival of healing cells. We further enhance the delay of healing by not moving and circulating the lymphatic system. As described above, we need movement in order to “push” the lymphatic fluid through its vessels. If we ice and rest directly after an injury you are delaying the healing process and prolonging recovery time.

Now that we understand the ice and rest do not remove inflammation, and that inflammation is not “bad,” do we want to stop inflammation? I would suggest that the wording here gets a little dicey. I would NOT suggest that we want to “stop” the inflammation. However, I would suggest that we need to promote the flow of inflammation. Much like a flowing stream of water to clean your dishes. If we simply pool the water around the dirty dishes they don’t get clean. Similarly, if we turn the water off completely (taking and anti-inflammatory medication) the dishes do not get clean either. The more flow there is to the water and the stronger the flow is from the faucet, the better the dishes get clean right?

This is similar to the concept of inflammation to a site of injury. There is an abundance of damaged cells which form debris around an injured site. We need to clean the site the best way possible. We know that ice and rest only pool the inflammation, and NSAIDs (anti-inflammatory meds) turn off the faucet. SO what should we do? How can we turn the faucet on higher and flush the injured site to clean and promote healing?

First and foremost I would suggest moving as much as possible in a tolerable and pain-free range of motion. If this is a minimal amount of movement, something is better than nothing. I would even suggest that even if no movement occurs at the joint level that to at least contract the muscles in the area. The contraction of muscles and the movement of joints is going to create the compression forces you need in order to promote lymphatic flow and “turn the faucet up”.

Once a good and safe movement program has been developed for the injured site, I would suggest manual therapies which have been shown to improve lymphatic flow as well. Compression and Elevation in the RICE acronym are components that should remain in the treatment plan. The compression will provide necessary forces to help lymphatic flow and elevation will provide gravitational forces to direct the drainage back into circulation appropriately.

From a manual therapist perspective, we can further improve the flow of lymphatic fluid. Soft tissue massage, compression/release techniques, kinesiology taping, manual distractions, and light joint mobilization techniques can all be used to improve lymphatic flow and promote healing. More on Massage

If you are interested in recovering as fast as possible from an acute injury and getting back to an activity you love I would highly recommend restraining from using Ice or Rest at all. Get moving as soon as possible, use some sort of compression device, elevate the injured site as needed when not engaging in an activity and visit a manual therapist to turn the faucet up from time to time. To reiterate, we do not want to pool the inflammation, nor do we want to remove it. We want to promote the flow of inflammation for the most optimal results in recovery time. Call for an appointment