An overview of ice therapy for acute injuries - by Katie Rendall, Physiotherapist
The following information does not replace any medical advice that you may have been given. It is always advisable to get an injury checked out by a health professional or Physiotherapist to ensure appropriate treatment and rehab can be given. A physical assessment should always be carried out and full medical history explored as appropriate. Please note that existing medical conditions can contraindicate the use of ice therapy, i.e. poor circulation; Raynauds; cold Urticaria, Erythema, Haemoglobinuria; loss of skin sensation or anesthesia; cardiac conditions, hypertension, superficial nerves and healing wounds. You should always check it is safe for you to use ice therapy before commencing.
DOES ICE THERAPY REALLY WORK?
This blog highlights the controversial topic of using ice therapy (also known as cryotherapy) for an acute injury, whether it’s a sprained ankle from bouldering or a finger pulley injury from crimping hard in the cold weather. We all know about using ice to reduce swelling and how it’s the recognised treatment advised by your nearest and dearest, and many health professionals. But does it really work and what is the evidence?
If you read my last blog on tissue healing, hopefully you’ll have a better basic understanding of how the body heals an injury and why it can take longer than you may initially think. Hopefully you’ll know a bit more about the inflammatory process being the initial phase of healing; a crucial and completely necessary part of the body’s immune system response to repair your injured tissues. But if this process involves a degree of swelling due to a natural widening of the blood vessels (vasodilation) to allow healing antibodies and white blood cells to the area (E. N. Marieb & K. Hoehn, 2010), why would we want to use ice therapy? Don’t ice and cold cause the blood vessels to constrict (vasoconstriction) which in turn prevents the inflammatory process from progressing to facilitate healing? You’d be forgiven for seeing the contradiction there and also probably being confused.
WHAT IS THE EVIDENCE BEHIND IT?
In addition to our physiological knowledge of the human body, Physiotherapists use evidence based practice to treat our patients. This means we use the available research trials and studies to inform our treatment to best help someone get better. Sometimes this can be confusing, especially if there’s a treatment that has been used for many decades but then new research or theories come to light that change things. Ice therapy often forms part of a wider treatment protocol called RICE (Rest, ice, compression and elevation) which was a term coined by Dr Gabe Mirkin in his book written in 1978, the ‘Sportsmedicine Book’. He was one of the original champions of the theory that ice as part of the RICE protocol can aid the healing process. However, he has since said that this may not be the case and healing could in fact be delayed by the use of ice therapy (G. Mirkin, 2015), due to the very physiological process touched on above. Aside from the issue of whether ice therapy slows healing, there are other suggested benefits for using it below:
There have been many research studies conducted on this topic, enough to keep you busy reading for days, and the jury is still out in terms of quality evidence to confirm that ice therapy, or even the RICE protocol, works. Over the last thirty years, the research appears to challenge use of the treatment protocol. When you examine the quality of the research available it becomes clear that better quality research is required on the topic going forward. To select an example of a common place piece of the evidence base, a systematic review (Hubbard et al., 2004) examined a small number of studies looking at whether cryotherapy is effective. They concluded that cryotherapy may have a positive effect but that the studies included were of poor quality, thus putting a question mark over the results.
A good quality review by Cheung (2015) also concludes that the jury is out but looks in more depth at the physiological response of hands and feet to cold therapy. In this article, the centuries old theory of the ‘Hunting Reaction’ is put forward. Whilst the immediate local vasoconstriction occurs as a natural response to cold, the very reason others have cited for delaying healing, the ‘Hunting Reaction’ is a return of blood to the area being cooled after a short while, which causes a proposed oscillation of vasoconstriction and vasodilation promoting the inflammatory process to continue (Cheung, 2015). Have you ever noticed how your skin goes red after a while of having an ice pack or cold therapy applied? This is where blood is returning to the area, possibly as a protective mechanism to avoid damage to the tissues (Cheung, 2015). It is recognised that the exact physiological response is complex and can be confusing but there appears to be more to it than ice therapy simply halting the inflammatory process in an acute injury thanks to vasoconstriction.
So, how do we determine, as therapists and even as individuals, whether we should be using ice therapy or not? To help us make sense of an inconclusive evidence base where better quality research would be helpful, there are NICE Guidelines. What on earth is a NICE guideline I hear you say! NICE stands for ‘National Institute for Health and Care Excellence’ and they produce guidelines for health professionals using the best evidence and research available for a particular injury or health topic. This can help make sense of the research from an overall perspective when it is somewhat unclear and there is an overwhelming amount of articles to read individually. So, what do they say about ice therapy? The more recent guidelines for the management of ‘Sprains and Strains’ (NICE, 2016) clearly recommend use of ice therapy as part of PRICE (the RICE protocol but with an added ‘P’ for ‘protection’) for management of acute soft tissue injuries. The best evidence available is used to underpin the guidelines but, of course, you are still free to examine the quality of this for yourself to make up your own mind.
TO ICE OR NOT TO ICE? THAT IS THE QUESTION…
Overall, there are conflicting views with evidence on either side of the fence. Many studies or guidelines talk about ice therapy as part of a RICE or PRICE protocol, adding in other elements not discussed in this blog. I have just covered ice therapy as the main discussion point as this has been the most controversial part of the treatment protocol and continues to be the go-to treatment for most sprains/strains. Going forward, if you do decide to use ice therapy and do not have any contraindications to the treatment, it is recommended by the NICE guidelines for 10-20 mins every 2-3 hours during the first 48-72 hours after injury, and the ice pack should be wrapped in a towel to avoid ice burns to the skin (NHS, 2017). Never leave ice on the skin if you are asleep (NICE, 2016). As always, you should consult your GP or health professional if you are in any doubt of how to manage your injury or are confused if ice therapy is appropriate for you.
In conclusion, the information available doesn’t give a definite answer on whether to use ice therapy or not, but presents some points for and against that certainly appear to make sense clinically. This blog is not designed to be a full review of all the research available, only to provide a brief overview, however, there are plenty of scholarly articles available for further reading if you are interested. I personally believe if you have a better understanding of the basics then you are better equipped to help yourself during your training and if injury does occur. Hopefully this blog is also an insight into how health professionals formulate treatment plans and where we get our information from; although experience tells us a lot, we don’t just make it up!
References and further reading:
Cheung, S. S. (2015) ‘Responses of the hands and feet to cold exposure’, Temperature. Vol 2, (1), pp. 105-120. Available online at: www.ncbi.nlm.nih.gov
Hubbard, T. J., Aronson, S. L. & Denegar, C. R. (2004). ‘Does cryotherapy hasten return to participation? A systematic review’, Journal of Athletic Training. Vol 39, (1), pp. 88-94. Available online at: www.ncbi.nlm.nih.gov
Marieb, E. N. & Hoehn, K. (2010). ‘Human Anatomy and Physiology’ (8th Ed.), Pearson Benjamin Cummings.
Melzack, R. (1996). ‘Gate control theory: On the evolution of pain concepts’, Pain Forum. Vol 5, (2), pp. 128-138. Available from: www.sciencedirect.com
Mirkin, G. (2015). ‘Why ice delays recovery’. [online] Available at: www.drmirkin.com/fitness/why-ice-delays-recovery
NHS, (2017). ‘Sports Injuries’. [online] Available at: www.nhs.uk/conditions/sports-injuries/treatment
NICE, (2016). ‘Sprains and Strains’ - Clinical Knowledge Summary. [online] Available at: https://cks.nice.org.uk/sprains-and-strains
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