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Giving ICE the cold shoulder

We have all grown up being taught the acronym R.I.C.E. for sports injuries, most commonly a sprained ankle. Rest. Ice. Compression. Elevation.

This is what I learned in school and what I read in every sports medicine book and what was taught in every sports medicine course. However, when looking at the literature, a different picture emerges.

The use of cryotherapy in sports injuries. Even as far back as 1986, research was skeptical. “Most clinical studies report that the use of cryotherapy has a positive effect on pain reduction and on the recovery of various injuries. When the physiological processes produced by cryotherapy are examined in experimental situations, some of these reactions differ from expectations.”

[Cold therapy of athletic injuries. Current literature review]. In 2001, this paper said, “Cryotherapy is often used in soft tissue sports injuries. The application of a cold pack reduces local muscular blood-flow by approximately 50% after 10 minutes. The duration of bleeding in a muscular injury is not known, but immediate application of external pressure is probably far superior in emergency treatment of an injury. Some studies have shown significant effect of cryotherapy in emergency treatment of ankle sprains, but external pressure is often applied simultaneously and the additive effect of cryotherapy is therefore uncertain. Cryotherapy reduces the metabolic rate in injured muscle and is often used several days after a soft tissue injury to reduce secondary hypoxic injury. Experimental studies, however, show no effect of cryotherapy on muscle regeneration, and no controlled clinical study has shown a significant effect in emergency treatment of soft tissue sports injuries.”

There was some thought that ice was more effective post-traumatic injury than when used post hard (eccentric) exercise. Effect of cryotherapy on muscle soreness and strength following eccentric exercise. “The result suggest that the use of cryotherapy immediately following damaging eccentric exercise may not provide the same therapeutic benefits commonly attributed to cryotherapy following traumatic muscle injury.”

Some papers discussing using Cryotherapy post-surgically, reported positive results. Increased comfort and decreased inflammation of the eye by cooling after cataract surgery. “Cooling increased the comfort level and reduced inflammation after cataract surgery, with no adverse effects.”

And some results were reserved. Therapeutic efficacy of cold therapy after intraoral surgical procedures: a literature review. “Ice applied after surgical procedures may reduce swelling and discomfort. However, data from studies regarding the benefits of ice therapy after oral surgery are inconclusive.” “There seemed to be consensus among clinicians that cryotherapy should be applied for 10 to 20 minutes followed by a rest period.”

This study, Effect of local cold-pack application on systemic anabolic and inflammatory response to sprint-interval training: a prospective comparative trial, suggests the negative effect on hormones which are part of the healing process. "...local ice therapy immediately following sprint-interval training was associated with a greater decrease in both pro- and anti-inflammatory cytokines and with a greater decrease in anabolic hormones. These results, along with the previously reported evidence for some negative effects of ice application on athletic performance, and no clear effect on muscle damage or DOMS may suggest that the use of cold packs should probably be reserved for traumatic injuries or used in combination with active recovery or massage and not with complete rest."

This next study, Blood flow after exercise-induced muscle damage found that ice decreased pain, but did not decrease blood flow after 48 hours. "Whereas eccentric muscle damage resulted in increased blood flow, ice did not decrease muscle perfusion 48 hours after exercise. Therefore, ice does not seem to decrease muscle perfusion when blood flow is elevated, as it would be during inflammation."

A 2014 study, Effect of ice massage on lower extremity functional performance and weight discrimination ability in collegiate footballers expressed the equivocal findings with regard to recovery and ice, stating, "potential negative effects of ice massage on proprioception are unknown." This study is interesting in that it questions why ice is effective for decreasing "cutaneous sensations" by its effect on the nerves in the skin that send signals back to the central nervous system, but it does not seem to effect proprioception. "The study resulted in the following main finding that both functional performance tests, single leg hop test and crossed over hop test and the weight discrimination ability remained unaffected with ice application. Our study has shown that proprioceptive acuity in the hamstrings muscle, as reflected in the ability to perceive differences in weight, is unchanged after 5 minutes of ice application." The final comment by the authors is that a rapid return to play after icing may not be detrimental.

This study,Effect of cryotherapy on muscle recovery and inflammation following a bout of damaging exercise, says that ice does not seem to prevent strength loss and soreness after muscle damage, but may decrease the rise of a protein that is associated with inflammation and muscle damage. "In conclusion, 20 min of cryotherapy was ineffective in attenuating the strength decrement and soreness seen after muscle-damaging exercise, but may have mitigated the rise in plasma CCL2 concentration. These results do not support the use of cryotherapy during recovery."


The effects of cold water immersion and active recovery on inflammation and cell stress responses in human skeletal muscle after resistance exercise from Australia "compared the effects of cold water immersion and active recovery [10 min. low intensity cycling] on inflammatory and cellular stress responses in skeletal muscle from [nine] exercise-trained men 2, 24 and 48 h during recovery after acute resistance exercise. The conclusion was "cold water immersion is no more effective than active recovery for reducing inflammation or cellular stress in muscle after a bout of resistance exercise." This does not mean that ice baths do not work, it means that they may not work by decreasing inflammation.

Effects of cold water immersion and active recovery on hemodynamics and recovery of muscle strength following resistance exercise states, "Cold water immersion reduced hemodynamics and tissue temperature, and helped to maintain muscle strength after resistance exercise. By contrast, active recovery maintained hemodynamics and tissue temperature, and reduced muscle strength after resistance exercise." Very interesting is that the authors stated that there was "tentative evidence" that cold water immersion increased parasympathetic output and active recovery decreased it.

Passive and post-exercise cold-water immersion augments PGC-1α and VEGF expression in human skeletal muscle states that cold wather immersion may contribute "to the formation of new mitochondria and blood vessels in muscle."

Wow! So, what to make of all this?

1. For "injuries" ice immediately after injury for no more than 20 minutes or until area feels numb, i.e. if the numbness occurs before 20 minutes take off the ice. Once you have made sure the area is stable, get right down to the business of removing swelling (by hand, cold laser, different types of E stim, kinesio tape) and restoring range of motion.

2. For recovery, try ice immersion if the training session was particularly hard (lots of eccentric work), if you must compete again within 24 - 48 hours, and you are competing in high heat/humidity.

Dr. Steven Horwitz Chiropractor Rockwall Texas Dallas Sports Academy

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