RICE: Yes or No

[physiomitch]

Hi all

Here is a little brain teaser, which relates to the management of sports injuries. I have for a while now been questioning the effectiveness of RICE in acute injuries and would like to add this to the forum to see what the reaction is. I believe it is comparing logic and common sense and human physiology to theretical practice. I may be wrong, but then.....

Some of the answers in some threads have mentioned RICE in the initial phases. I have a few things which might make you think about this differently. Although it is widely held that this is an acceptible approach to use for acute injuries, I feel we may be missing the point here. Theoretically ice reduces swelling, inflammation and pain, restricts blood flow to reduce bruising, however, this is theory, and yes these are the effects of applying ice to the body. But why would we want to starve an injured area of a natural blood flow for anything up to an hour. Inflammation, swelling, pain, bruising are all natural part of the injury process, BUT THEY ARE ALSO NATURAL PARTS OF THE HEALING PROCESS! Without these the brain will never know for sure the injury occured. So reducing these inputs can severely diminish the body's ability to repair itself. Where is the research to prove RICE helps the repair process or shortens the recovery period of an injury? I have not seen any, just as I have not seen any regarding ice baths! It is a SYMPTOMATIC APPROACH, not treatment approach. The ironic thing is that if injured and left to its own devices the body responds with vasodilatation in the injured area, NOT vasoconstriction, which goes against anything we have been told. So if the body itself increases the blood flow to the area, why are we shutting it down? For repair to begin the body needs platelets, red and white blood cells in the area, so it makes sense to increase the amount of blood in the area, but this takes place almost immediately, yet if we restrict blood flow, this cannot happen. Bruising will eventually stop as blood vessels repair quite quickly, so we should not worry about that and swelling is from damaged cells...they cannot get any more damaged and only have a certain amount of fluid in them.

In my opinion we should focus more on trying to influence more blood to the area, not away from it. This can be done by using small doses of ice (10 secs at a time, removed until the skin warms up again), below the injured area if possible to stimulate flow THROUGH the injured area, not around it which is what happens with orthodox icing.

My opinion: RICE...rest, yes. Ice, NO!

What do you think?

[Canuck Physio]

Interestingly, common pain relieving gels which contain ibuprofen as an active ingredient also inhibit the inflammation response that is necessary for tissue growth and repair.

One thing that guides clinical practice is usually patient response, if patients feel like they are better or at least something is being done about pain relief then naturally this will guide practice and may be one of the reasons that this practice is so commonly quoted.

Else, there is very little we can truely do to gauge the response to injury. We simply do not have the equipment necessary to measure the inflammatory cytokines, and especially not the neurological response to injury, so in many cases we can not truly establish the best technique or method for acute post injury.

[physiomitch]

I hear what you are saying. Gels unfortunately do do what you say, they also contain Isopropyl alcohol (cooling agent) a known carcinogenic! I agree patient feedback is necessary, but if it was explained to them that ice could be harmful in the long-term, maybe they would refuse it anyway, and rely on natural means of easing the pain, like rubbing, gentle movements etc. As Physios I believe it is our job not to worry too much about the chemistry but concern ourselves with removing any obstacles getting in the way of the body healing itself. Granted a little pain relief can be beneficial, but maybe in smaller doses as I mentioned. I use this approach for my local rugby team and get fairly good results. I believe the fact we can feel the symptoms, gives us a better idea about how the body is dealing with it. Remember the body has access to endorphins 50+ times stronger than morphine, so if it feels it needs them it will activate their release. I have seen a drunk guy black out 1 minute after being hit in the ankle by a passing car, but he managed to get to the other side of the road and sit down first, then...poof! I just think there needs to be a little more research into this as far as aiding repair, not just treating symtoms.

Cheers

Pete

[Canuck Physio]

Here is some very recent evidence:

OBJECTIVE: To determine if ice-water immersion after eccentric quadriceps exercise minimises the symptoms of delayed-onset muscle soreness (DOMS). DESIGN: A prospective randomised double-blind controlled trial was undertaken. 40 untrained volunteers performed an eccentric loading protocol with their non-dominant leg. INTERVENTIONS: Participants were randomised to three 1-min immersions in either

• ice water (5 +/- 1 degrees C)
  or tepid water (24 degrees C)

. MAIN OUTCOME MEASURES: Pain and tenderness (visual analogue scale), swelling (thigh circumference), function (one-legged hop for distance), maximal isometric strength and serum creatine kinase (CK) recorded at baseline, 24, 48 and 72 h after exercise. Changes in outcome measures over time were compared to determine the effect of group allocation using independent t tests or Mann-Whitney U tests. RESULTS: No significant differences were observed between groups with regard to changes in most pain parameters, tenderness, isometric strength, swelling, hop-for-distance or serum CK over time. There was a significant difference in pain on sit-to-stand at 24 h, with the intervention group demonstrating a greater increase in pain than the control group (median change 8.0 versus 2.0 mm, respectively, p = 0.009). CONCLUSIONS: The protocol of ice-water immersion used in this study was ineffectual in minimising markers of DOMS in untrained individuals. This study challenges the wide use of this intervention as a recovery strategy by athletes.
Author/Association: Sellwood KL, Brukner P, Williams D, Nicol A, Hinman R
Title: Ice-water immersion and delayed-onset muscle soreness: a randomised controlled trial [with consumer summary]
Source: British Journal of Sports Medicine 2007 Jun;41(6):392-397

[Canuck Physio]

However, having said that, it appears that other evidence shows that Contrast Ice Water therapy is effective at decreasing DOMS, and increasing Power output capacity post Exercise!

[physiomitch]

I guess one of the problems with our modern day demands on top sportsmen and women, is the need or perceived need to do more to get more, so they are trying to find ways of disguising or hiding the normal reactions to exercise, and pushing the body beyond its naturallimits. Interesting research done 10+years ago showed the white blood cell count, after rising during exercise, fall to below normal levels and only recovers to normal resting levels 48 hours after exercise. I will be surprised if this is altered by icing or ice baths. Thisis typically eveidenced in runners training for marathons who when they reduce their training in the last 2 weeks before a marathon, often come down with flu or some similar condition, as there is now nothing to kick the immune system into higher rates than normal. In essence, exercising every day, can lead to slow but sure fatigue and weakening of the immune system. Makes you wonder why the lifespan of a top athlete or player these days is so short. There seems to be more concern getting athletes back on the track ASAP after the last session, that the long-term effects are ignored. Still not sure something unnatural can be healthy in the long-term.

Pete

[feroz]

RICE is updated PRICE is the best principle for the treatment of soft tissue injury

[Canuck Physio]

This is an interesting topic area up to much debate,

Additionally some research suggests that it is in fact chronic inflammation that is the cause or the pre-emptive strike on the human body that leads to accelerated aging, and chronic disease.

Although free radicals are normal byproducts of metabolism, they are very active chemicals and can damage the inside of your cells, causing inflammation. Inflammation is the hallmark of many chronic diseases including Alzheimer’s.

It is also normal after exercise for there to be suvere immune depression, and the object of nutritional therapy combined with exericse therapy is often to increase cellular glutathione levels for instance to quench these free radicals.

It appears to me that along with physical manipulation, cryotherapy, and other modalities to healing, intrinsic anti-oxidant quenchers must be increased as well.

[physiobob]

Tend to agree in principle. However the "ice" part is to reduce excessive swelling to the area and for pain modification really. It does not stop inflammatory processes "OR DOES IT". All it does is slow flow thereby reducing damage to tissue by excessive swelling to the surrounding tissue. Kind of like control a crowd leaving a football match rather than a stampede all at the same door at the same time. They all get out but don't kill each other on the way.

I think the better question here is "Does the Icing reduce inflammation?" or does it merely slow it down to an acceptable delivery rate?

[physiomitch]

Sorry, please read this after the above reply.

Just a further point on use of hot or cold in general. We need to keep aware of what is termed 'reciprocal blood flows'. This means we have a closed vascular system with a set volume of blood, and thus the body regulates the pressures to maintain a a balanced internal environment. Now if ice is applied to the skin, the surface blood vessels constrict, but to maintain even blood pressure, blood vessels somewhere else will have to dilate. This is known as reciprocal blood flow. So icing an injured area causing constriction will mean initially muscle vessels will compensate by dilating, but the longer the ice is applied, the deeper the compensation will become. Thus blood can actually be diverted away from and around an injured area to maintain good pressure and flow rate.

The converse with heat; this causes dilatation in the skin meaning there has to be constriction somewhere else. Examples of reciprocal blood flows are: between the skin and underlying muscles, between internal and external carotid arteries, between skin and gut, and importantly between paravertebral skin and spinal cord (can be harmful using cold or ice on the back resulting in congestion in the spinal cord).

Another reason maybe not to use ice for so long? Ideally we want to maximise blood flow RATE to allow the body to initiate the healing process. Interesting to note how acupuncture practitioners in the east treat acute injuries...they needle around the injured area (trapping the Dragon), essentially causing MORE injury, enhancing the body's processes, not stagnating them.

Pete

[physiomitch]

It is a good question. If you look at the physiology of injury again inflammation and vasodilatation go hand in hand. Various substances such as the amines (histamine, seratonin etc.) and prostaglandins, cause vasodiltation as part of the inflammation process. However I feel there is a misperception about blood flow. Dilating blood vessels does not increase blood flow, it increases blood volume. The rate of blood flow is important in good body function and if a blood vessel dilates, the rate will slow, just as a river will flow slower when it becomes wider. If the rate of blood flow is maintained by increase heart function then this is OK, but if not then there will be a slowing of blood flow rate.

At the same time blood pressure in the vessels can only increase if 1) The heart works harder to counter the dilated blood vessels and initial drop in pressure, or 2) if there is a blockage at the end of the vessel causin a backlog of blood. The reason for vasodilation in the injured area is to allow better permeability of fluids in and out othe the blood vessels, but also to allow a slowing of the rate of bloo so the necessary cells have an oppertunity to adhere to the damaged blood vessels or penetrate the blood vessels and adhere to the injured tissues. This is done electrically, as the injured area will be initially positively charged (internal cell fluid leakage), and all red and white blood cells and platelets are negetively charged. It is not a chemical attraction.

So again my question is: if vasodilatation is normal in injury (and apparently only lasts 10 to 15 mins), as a part of the inflammatory process then how can we be doing the body any favours by causing vasoconstriction? Logic indicates that this would reduce the inflammatory process as the necessary mast cells, red blood cells and other chemicals cannot get there in enough quantities to do what they are meant to do. It seems that we have been brainwashed into believing that if we do not treat with ice we will continue swelling or bleed to death, yet the blood vessels are immediately repairing themselves and vasodilatation only last 10 to 15 mins, so the body has the ability to control these factors, but it needs the process to continue to be able to do a sufficient job.

Again, are we helping the longer-term repair by icing or are we hindering it? Should we go against the body's natural practice and treat symptoms or should we allow the body to continue its natural methods and assist where we can?

Pete

[elinekk]

Hello everyone,

Ice is a very invasive way to reduce swelling and there are more ways that lead to Rome.
Elevation of the injured part, above the head, reduces the bloodflow in the area as well, preventing other tissue to damage from excesive swelling but does provide the area sufficiently.
Like some people have said, it is natural for the body to have an increased bloodflow to the damaged area in order to start of the healing process.
The reason ice has been used for so long is that it reduces the swelling promtly and dims the pain, for an athlete to return to the field straigh away or to, so they think, recover quickly.... (Even though recovery will not be made fully and and good as through the natural healing process, after all, blood provides for that.) Do understand that in sports, especcially in team sports, the rule "For you 10 others" count and sportsmen will take the risks to make to team.

I also read someone writing about Ibruprofen and other anti-inflamation drugs. Also with these I would be carefull as they stop the natural healing process of inflamation and research has found that tissue regrowth is not as good and strong as when no anti inflamation drug has been used.

Great to see so many people get into this kind of discussion and what a great toppic. I think its good to question the 'rules' at times, after all we are a developping trade, right.

Kind Regards,
Eline.

[Dr Damien]

I am a bit upset that as physios we seem to be in the business of confusing each other rather than making things clearer. Someone brought evidence on the inefficacies of cold water immersion on DOMS, just one evidence and we are only following suite. what happened to the heirachy of evidence trailing?where consistent evidence from one or two RCTS or systematic reviews maybe?
There are evidences out there suggesting that the same ice water immersion is effective, the only cryotherapy technique investigated in addition is ice massage and that has been proven ineffective.

We need to look at the bigger picture first. DOMS is not a normal acute muscle lesion like a strain.Reasons, it is a readaptive remodelling process hence further injury does not occur with subsequent eccentric exercise rather symptoms go down. secondly, unlike strains, focal myofibrillar disruptions occur but strains often occur along the length of the fibers, thirdly the symptoms of DOMS are independent of each other and occur and resolve at relatively different time scales. It takes about a week for a muscle affected byDOMS to recover but in strains 3weeks. the highest intensity DOMS as shown in the literature takes maybe 2weeks at the most. so therefore even if ice does not work for DOMS it does not mean it should be questioned for classic strain injuries.two different things entirely, dont get it twisted.

Inflammatory indices and myofibrillar indices are very unreliable when used as markers of DOMS muscle damage because they can get cleared from the system easily and individual response is variable. Gender and age have been identified as possible factors predetermining DOMS. So how can you compare the effects of ice or immersion on DOMS with strain injuries?
I left a thread correcting the false notion on ice left by physiomitch in order to bring back the false brain teasers left due to mis information.Before you give judgenment on any paper u should learn to critique and appraise it. That way you make judgements as a true professional not a technician.read the literature on DOMS again not just one paper and get the clearer picture. Read the literature on Ice again and get a clearer picture and stop confusing busy physios who do not have the time to check this evidences themselves.

Please, please, please leave ice alone...or else you will be managing sports people wrongly and causing more damage. If anyone is looking to think laterally, let it be along the lines of what you have been doing that has not worked.then you have basis for argument, its all about making the practice better and more effective.

Vasodilation in acute injury is accompanied by, leaking blood vessel membrane, extravasation of fluid and swelling. True inflammation is needed and it is needed to only ensure that scar is formed. You have been too concerned with vascular responses alone, cell mediated hormonal responses also occur. If inflammation is not controlled, SECONDARY HYPOXIC INJURY WILL OCCUR! plus further damaging the tissues because nearby cells will die(APOPTOSIS) and leak out substances that hurt and kill other cells. inflammation directs fibroblast and macrophage activity and that is
important however excess inflammation leads to too much scar , adhesions and deformity. GET IT! so ice is not only concerned with vessel diameters, there is a bigger picture to see. Please stop confusing people. the body can vasoconstrict on its own and it surely will depending on vessel or area injured which means larger vascular injuries will take time to plug, by that time do u know how much hypoxic starvation of cells could have occurred? you need to control inflammation, ice does not cure, it controls inflammation and is discontinued once inflammation is believed to be appreciably controlled assessed by pain and swelling. GET IT!

the only damage you will get from ice is if u leave it on for too long or the patient finds it hard to tolerate. If you do not use ice in an acute phase and u use the other option heat this is what will happen. vessels that are damaged will further expand leaking out fluid from their membranes and causing more swelling and pain. why would you want to do that to ur patient?

your idea about compensation from the cardivasular system is odd because the only areas the CVS holds priority are the vital organs and brain. hence you have peripheral shut downs and maintenance of core temp in cold situations. If the CVS can do that effectively in a cold weather, do you think a measly 20minutes of local ice to an area not even the sized of the fist would be a problem?think about it logically. If anything at all you should be screening for contracindications e.g vascular diseases, heart conditions etc.
I hope this puts an end to this brain teaser that is seriously backed by either misinformation or pure misinterpretation of good information.

[raggedblossm]

Damien,

I appreciate all the new information in your reply. It is very informative and adds to this discussion (although I had a little difficulty separating it from your frustration).

Personally, I have found this thread PhysioMitch started to be quite useful as an academic exercise. I like to be challenged in my thinking as a physio and I am not threatened by that. We are all being challenged as physios these days to become more evidence-based in our practice and so I think a discussion on the RICE protocol is quite appropriate.

I do think, however, Damien, that you did not read the other posts (above) very well. Perhaps you would like to read them a little more clearly before your next response. My pet peave on the PhysioBob site is people who post quick replies to questions which do not properly address the issue at hand. They simply did not adequately read what had come before. As physios we are supposed also to be good communicators - getting all the facts from our patients in order to understand how to help them. Let's all practice that here too.

Thanks to everyone who has posted here. I have enjoyed and learned from this discussion.

[Dr Damien]

I apologize if I sounded a bit frustrated, i would be the first to acknowledge thoughts that are strongly evidence based but this was not.
I did read the replies by the way but thanks for letting me know where my communication went wrong.

[Canuck Physio]

Hello,

I did post a link to one study, but no where did I state that this is the be all and end all of cryotherapies role in physiotherapy treatment. The intent of the post was to show that there is disagreement between some studies, and it is very difficult for us to measure the true or clinically meaningful effect of any given therapy. Physiotherapy treatment in general will in many cases be a maximum of 8 say, on the Pedro scale simply because for most modalities we simply can not blind the patients or the therapists to the treatment, and not to mention the influence of the Placebo, Nocebo, and Hawthorne effects!

The key issue is there are studies evaluating the use of certain conditions, and we aught to be aware of what is the most effective treatment (regardless of whether or not we know the 'true' physiological treatment effect).

I believe Cryotherapy is very useful based on personal use, but I also understand that certain forms of cryotherapy are far more effective than others. For example, I do believe that ibuprofen cryo gel's inhibit repair, just as after a bout of intense exercise the normal hypertrophy post exercise response is blunted by ingesting ibuprofen. It is important to understand and question the physiological basis of any given treatment, else we may continue to do same old without realising our err's.

Good post btw.

[Dr Damien]

I agree quite frankly. blinding is a problem only because of ethical issues mainly. In other countries where ethical issues are not that stringent trials are adequately blinded. The pedro scale is limited in content in some parts and except i am mistaking it for the modified version, it mentions nothing on sample size or power calculation.
Assessing quality of a study goes beyond just blinding,you still have other options e.g sample size , randomization etc. The study design will help one decide whether to assess it stringently or give it some leeway. You identify only RCTS somewhat in your point.
My point in response to your reply is that, first of all clinically meaningful effect, yes very difficult to assess on a personal note except you have a wealth of experience however some studies do report it. It is important that a good study gives some clinical relevance either in the discussion or statistcally not just statistical significance.

I think when it comes to cryotherapy, the basis behind the effect should be acknowledged first. If any contradictions must be raised then it should be in scrutiny of what has been claimed, what is experienced(by that I mean thorough reflection of one's own practice) which means we should at least try and be familiar with the literature before we put out ideas. if I told you the earth was flat and the UK was the world will you believe me? NO, because you know better and you know better because you have seen the world from Tv or probably have travelled to other parts of the world;well if I told that to a two year old then I would be misinforming that two year old, init?

If a lot of new physios assess this site on a regular basis hoping to get quality info then it is our duty to make sure that happens.

I would have agreed with the subject if the thought was lets try other treatment possibilities not lets try other treatment possibilities because this is not effective when clearly I know only a tiny part of the story, that is being biased.

The only way to know what is most effective is if you pit both treatments against each other in a trial but before you can do that again you need to be aware of what each treatment does or what has been claimed it does right?

and if the literature is limited in that field you would be justified for trying something new. Nothing was mentioned about types of cryotherapy modalities, nothing was mentioned about depth of cooling, nothing was mentioned about lasting effect of cooling etc yet the thought was vasodilation, the way the body heals itself. Yes the body will heal itself but cryo is not giving for symptomatic relief. Read any current paper today and the first thing you will see is it is given to prevent secondoray hypoxic injury which will occur from metabolic demand on starved tissues when the area is hot. That is the primary concern, pain reduction and swelling happen to follow suit.

the idea is to make sure cells dont die anymore.The body increases vasodilation but remember reperfusion injury occurs.these are the reasons why cryo is important.

If physiomitch had presented his case saying, "hey guys look cryo is claimed to do this, decrease metabolism to prevent hypoxic injury but after searching I could not find one study that supported the idea" then I would have been like"really?, interesting so we have been lied to!"

Physiomitch said he gets fairly good results from trying low dose cryo. It should be excellent results if it was sound. I agree that studies tend to show equivocal results most of the time, this is where the physios critiquing and appraising skills come to play.

If you treated a few minimal sprain injuries and you get excellent results all the time with any treatment, that does not mean you will get the same results if the sprain was really bad.

To finish up, You say we need to be aware of what the most effective treatment is and that there are studies out there. Couldnt agree with you anymore on that, but how do you know which treatment is effective or which study is meaningful when you are not informed ?

I do not believe cryotherapy is the most effective acute soft injury management out there but I would not castigate any treatment until I am scientifically aware of everything about that treatment. That is how a true scientist thinks. I just read in the papers today, British medical experts and scientists have travelled outside the UK to do what?, investigate the secrets behind the health"INESS" of rural countries and remote tribes who do not even have a healthcare system.

I'm sorry if I misread your train of thought.

[Canuck Physio]

I understand what you are trying to say, although I don't realise what we are discussing now

It is probably important to keep this in context, I am not trying to claim the earth is flat, and I don't do anything of the sort when providing treatment to a patient. I feel it is important to inform the patient, and thus it is important to use a variety of literature (sys reviews, RCTs, etc) which are ethical, have stringent quality of methodology, and are peer reviewed.

If we take for example Chiropractic in North America, which initially began as an 'Art' of spinal manipulation and a treatment modality for 'subluxations'. And many unscrupulous individuals consistently tell patients that they 'need' or 'require' x amount of sessions. Other examples include certain electrotherapies that are touted to work, but lack sufficient evidence.

By providing the above example I am not trying to antagonize either, rather they appear to have their use in certain situations. This is key, and it certainly is the case in many physiotherapy modalities.

Another example includes stretching, for many many years it was considered the norm to stretch (static) before a workout (lets say weight training session) to avoid injury. But significant and mounting evidence just shows that this is not the case, and in fact static stretching before weight lifting attempts decreases subsequent force output. Yet, how often does static stretching take the place of an appropriate warm up before weight training?

In regards to this subject, I agree with cryotherapy and I am not claiming that it has no use in RICE.

"Couldnt agree with you anymore on that, but how do you know which treatment is effective or which study is meaningful when you are not informed ?"

My personal opinion is that the mind-body power effect is quite powerful, and results of many studies (placebo, nocebo, hawthorne effect) can certainly sway the quality of a study. For this reason there is debate about this very topic, what is the role of acupuncture, what is the role of electrotherapies, do they work, if they do what specifically for? I recently reviewed (personally) all the literature surrounding constraint induced movement therapy CIMT, and I can not say for sure that CIMT is any more useful than Neuro Development Training (NDT) at enhancing function in Post-Stroke patients, but I am sure that Taub and his followers are quite adamant that it is the revolutionary therapy that will change the world.

So basically, I am not 'castigat[ing]' cryotherapy in any way, I think that we should consider the evidence to inform clinical decision making.

Personally, I have seen great success with Cryotherapy. But sometimes patients respond better to heat therapy than cryo.

"That is how a true scientist thinks. I just read in the papers today, British medical experts and scientists have travelled outside the UK to do what?, investigate the secrets behind the health"INESS" of rural countries and remote tribes who do not even have a healthcare system.

I'm sorry if I misread your train of thought."

I got another good one for you:

Why is it that US which spends the most money towards medicare and pharmacology, has the highest rates of cancer, diabetes, hypertension, and disease in the world? On the other hand, Cuba which spends some of the least towards a virtually negligible medicare system, has the lowest rates of cancer, diabetes, hypertension, and disease in the world?
I think this is where Physiotherapy will play one of the largest roles in the future, but that is up to debate (that is prevention).

And I would say that this is an interesting discussion, it is one of the first I have seen on this forum in a while.

[physiomitch]

Hi All

It seems I got more than the ball rolling!!!

If I may clear something up. I don't believe that anyone in this thread has ever doubted the use of cryotherapy or that it is effective, I think the idea was to explore the possibilities of, if not alternative, then different methods of use of ice in an acute injury. There was never any criticism of any research, just bouncing ideas off the wall. If any Physios were confused by this I apologise, but I think free thinking is what we are all about, and we are entitled to question things no matter how apparently secure the research may be. Those that follow mainstream research and news will obviously base their approach on what they are exposed to. This does not mean there are no other ways.

As a matter of interest on the question of vasodilatation and sympathetic control, the body is full of what is termed 'reciprocal blood flows',(Dr Frederick Erdman-The Control of the Circulation) meaning if one area of the vascular system constricts another area must dilate to restore blood pressure, as the vascular system is a closed system and thus a set volume of blood. If there is fault in the function of the sympathetic nervous system blood flow can be altered in areas of poor control (vasodilatation or constriction) but this must be countered by an opposite reaction in another part of the body to maintain balance and BP. So applying eg cold over the skin of the spine causes local constriction, but the reciprocal blood vessels in the muscles dilate. The longer the cold is left on the deeper the response. This function allows the body to move volumes of blood around the body to areas in demand, an extreme example being the flight or fight reaction. Therefore we might need to be more circumspect when applying ice or heat, and be aware of reciprocal reactions. This is just a different way of looking at circulation and makes me wonder if traditional approaches can be improved upon or not.

In conclusion, as I have mentioned before that my general question has never been how ice affects the body in injury time, but whether it is beneficial in the repair process as a whole in terms of fascilitating optimum healing.

Cheers

Pete

[raggedblossm]

Thanks Pete,

That's the way I understood it too.

Linda

[physiomitch]

Hi Canuck

Sorry, your reply sparked another interesting fact...(or fiction??)

If we are supposed to warm up before stretching, why do animals instinctively stretch before getting going after resting?

To All... I think we can learn a lot from nature, and observing nature, as nature does'nt care much about research, only survival. (Back to RICE) Do you think an animal would instinctively dip its arm or leg in an icy river if it was injured? Would WE have done it instinctively if we were not aware of the effects of ice on the body? Is it possible that too much information can twist the laws of instinct? I wonder what the indigenous tribes do , that is those not exposed to modern western approaches? Is it that ice is convenient, and gets another quick fix, and research has had to be produced to back this up? We live in a world of demand for the quick fix, so is ice any different. I would be interested if you ask many sports Physios why they use ice, whether you would get the answer supplied by Dr Damien (no disrespect to quoted effects), or whether you would get an answer more like...'to reduce pain and swelling and inflammation'? Maybe the teaching is not good enough in this respect. Excuse the synicism, but I have seen too much evidence of biased research, and am always a little bit sceptical of research that finds its way into mainstream media, as the media is controlled by big business...and money. Anyway, enough of that, don't want to suddenly vanish from the face of the earth

Maybe we could get some more sports Physios to give their input

Sounds like another chapter from Hitchikers Guide to the Galaxy...

[Dr Damien]

Okay,
So I realise this was not a run down of Ice therapy all along, My Bad. I will give a speculated guess to physiomitch's question. Ice therapy will not be beneficial to the repair process but it will be beneficial in the inflammatory process and i tell you why.this is a speculated guess but it has good reason.

Before I get back to that, I'm sure we all know that every single treatment technique is claimed to promote healing. the only thing the facilitates healing is nutrients from good fresh blood. Nothing else can do that hence if there is a problem with circulation, respiration or last phase of digestion then most likely healing will be slowed(you see that withmost common systemic diseases,loss in appetite, breathing problems, weight loss,lowed immunity). But then again if fresh blood comes in and the tissues are not able to recieve it because they are dead or the environment is not conducive for them to operate properly(osmosis and diffusion and whatever means of molecular transportation there is) then give all the blood you want to, nothing will happen. hence in infection, the primary reasoning is control watch factors that can increase circulation and if you must, then antibiotics must have been used. if not you would only spread the infection, provide nutrients for foreign organisms rather than host cells etc.

coming back to how ice therapy will not aid repair, in the repair phase a lot has been taken care of, phagocytosis has occurred, new vessels have been proliferated in short the area is now green for vegetation. You bringing ice in starves at that point that is why customary physio practice suggests the use of heat in chronic or long standing cases(and I use the term long standing loosely to mean anything after the sub acute phase). I will give an analogy, burning down a forest ruins the productivity of the land but in a few years fresh organisms will arrive to get the area revitalised and most likely the new organisms will not resemble the old ones that were there before.

So therefore ice will not help repair.

this is where Ice will help the healing process as a whole. By slowing down the rate of inflammation, heat and all them inflammatory agents you are stll able to keep some cells alive. which means your overall transition from acute to subacute to chronic is reduced. if not healing will take a longer time.how much longer?you need a good and well designed study to find that out?probably only effectiveness may be measured because I do not know how ethical it will be to hurt subjects and then see how soon they get better with ice or some other treatment.

but that is all theory, lets imagine we did not give ice. swelling occurs, inflammation is hot vessels are well dilated after being injured, blood comes into the tissues who are stressed already because the place is really heated up(heat causes increase in metabolic rate),the are struggling to take in the new nutrients but they are working at a harder pace, their membranes are ruined, the are recieving noxious substances that threaten to kill them. pressure from swelling is bursting their membranes further,finally everything settles. and it will not settle until the very last stressed severely stressed cell in the vicinity is dead, because that is the only way metabolic rate can decrease. Other cells are safe, but we have left a mass of dead cells which we can not see.

the concept of rest is to provide support to avoid further injury, but rest will also minimise the metabolic stress on that area.Imagine having a strain and still getting the muscles actively working at the rate the would work when they wer not damaged. That is why pain and muscle spasm happens to prevent too much use.

if ice slows local metabolic rate then it promotes healing in that sense. The questions should be, does ice really slow metabolic rate?ice does not aid repair,because it is not needed for repair, infact it is contraindicated in book for repair.

Orthopedic medicine management of musculoskeletal conditions recognises that. so every treatment is graded according to stage in the healing process.
the use of mysofascial release is needed, question is how much and when is it needed?

So rather than asking a question does ice help repair(because it does not), it would make more sense to ask when should I be using ice or why am I using ice in this situation?

Before you can make a direct comparison to nature you need to understand that what nature feeds on is pure. We eat all them burgered slub, cheese and what not and we want to be as free as nature. I think that is funny. A lot of us(myself inclusive) dont have the body that nature designed for us to have. The indigenous tribes you mention eat so many herbs that we in this part of the world can only imagine. They do not have the oily concenterated food that we eat. So how can we compare ourselves to them.

If researches are big businesses alone then how are you able to know what you know?How can one not say for sure that what you have propagated may not have come from dodgy research evidence as well? we wont say that because we know you are capable of dileneating truth from fiction.

instintively, when you touch something very hot or you get burned or an area is hot what do you do?

I think if cells did not die in the early stage of inflammation then ice will be wrong to use but that is not the case.

Other therapies can be considered but there is always a guide to speculate what will work and wont and that is the stages of injury itself.

By the way...I agree with you too much evidence has its side effects.

[Canuck Physio]

Hi Canuck

Sorry, your reply sparked another interesting fact...(or fiction??)

If we are supposed to warm up before stretching, why do animals instinctively stretch before getting going after resting?

In terms of optimizing performance for sport (high intensity weight lifting, sprints, etc.) mounting evidence is beginning to support forgoing static stretch before these particular strenuous events.

Researchers from the University of Kassel in Germany investigated the effects of stretching on various jumping performance tests such as the drop jump, counter-movement jump, and squat jump.

Stretching was performed at various intensities prior to the jump tests. Regardless of the type of stretching involved, the data showed that all stretching protocols resulted in a significant decrease in jumping performance. For example, static stretching resulted in a significant decrease in performance in all tests by 5%.

This is just one example, from the European Journal of applied Phys 2007.

Other studies seem to back this up, in that passive stretching before high intensity muscle contraction will reduce the ability to produce maximum force. Additionally, it’s also been confirmed that stretching before exercise is not linked to a reduced risk of muscle injury. So stretching before training won’t protect you from tearing a muscle. Stretching is an important component for building strength and improving athletic performance as it increases/maintains range of motion of the joints. However, stretching should be left until after the hard work is done.
Medicine & Science in Sport & Exercise, 36, 2004

Most (if not all) studies that have examined the effects of stretching prior to weight training have used people that have no stretching experience. However, a recent study has taken this into account by examining the effects of stretching before strength and power testing in the gym, using people that have prior experience with stretching.

This study used college-age males and females who had followed a stretching program provided by the researchers for at least 10 weeks prior to the study. The participants weren’t avid weight lifters or bodybuilders but they did participate in a variety of recreational sports. The stretching program and muscle testing involved the hamstring muscle group. The hamstring curl exercise was used to assess strength and power development. The strength assessments were completed on several occasions before and after stretching the relevant muscles.

The researchers discovered that even people that had undertaken a stretching program, still experience a decrease in muscle strength and force development if they stretched prior to strength testing. Therefore, even if you have stretching experience, it still does not seem like a good idea to stretch extensively before your strength training.

Source: Res Quart Exerc Sport 76;500-506, 2006.

Additionally, I know I have nit picked with only a few studies. But I have yet to discover any evidence that says static stretching before intense activity can reasonably improve or at least maintain peak performance during any activity.

To summarise:

1. Static Stretching before Intense Exercise appears to prevent maixmum muscular force output.
2. Inconclusive evidence that static stretching as opposed to dynamic or acclimatory warm up is useful for preparing for High intensity exercise
3. Inconclusive evidence available to show that static stretching BEFORE exercise prevents injury
4. Static Stretching is definitely useful for maintain joint range of motion, and flexibility, although it is unknown whether it is best to stretch directly after a workout or later or several hours earlier

Regards

[Dr Damien]

Canuck physio

I doubt if you will find anything that supports preexercise or postexercisestretching although one study reports the benefits of yoga.

pre stretching may even be predisposing to injury, dont you think? with muscles not contracting maximally and all, lack of full joint control by dynamic stabilizers may be predisposing to injury.

it may even be more predisposing to DOMS since the initital length of the muscle is a factor under high intensity eccentric exercise regimes.
what do you think?

[Canuck Physio]

Hello,

I would be interested in reading the study on Yoga would you know what it is called? At least one study I have read shows that Yoga post work out can enhance recovery between repeated bouts of strenuous exercise.

Indeed, if pre-stretching has the action of inhibiting neuro-motor output to stabiliser muscles , I definitely see the potential to increase risk of injury.

Interestingly I wonder why they haven't re termed stretching , as Manusson et al. (1998) suggested that muscles viscoelastics do not in fact change, rather it is the neural adaptiveness that is needing to be considered - hence effectiveness of PNF.

DOMS appears to be elicited more frequently during High load Eccentric Exercise movements (ballistic, weight training etc.) that is true. I can imagine that if stretching is done before this it predisposes the joint to greater instability, but DOMS is one area that scientists are still having a hard time to figure out, and I have to admit it is something that I wish I could block out on a daily basis!